Normal Operations Safety SurveyNormal Operations Safety SurveyAirservices AustraliaAirservices Australia

Marcus KnauerMarcus Knauer

Normal Operations Safety SurveyNormal Operations Safety SurveyAirservices AustraliaAirservices Australia

Marcus KnauerMarcus Knauer

Why are we here?

• Member of ICAO NOSS Study Group.

• Undertook First Operational NOSS Trial April – May 2005.

• Share our experience.

Current Data Sources?

•Electronically Submitted Incident Reports.– Incidents.– Events

•Technical Fault Reporting.

•Audits– Regulator/Internal - compliance

•Check and Training reports.

NOSS Trial

Focus:

Trial implementation was used to determine whether such a concept was appropriate within an ATS environment.

Whether the methodology developed to date by the ICAO Normal Operations Safety Survey Study Group (NOSSSG) was suitable.

Valid Snapshot of Brisbane Centre Operations

What we did.• Controller Association briefing.

• Joint Management/Union sponsorship.

• All controllers received TEM briefing.

• Publicised project and its intent.

• Created a NOSS web page.

• Observers selected were jointly nominated by management and union.

The Trial • 5 Observers, 5 Groups (Radar Enroute and

Arrivals)

• 1 week Observer Training– Theory, 2 trial observations, calibration session.

• 2 weeks Data Collection– 52 observations – 292 threats– 139 errors– 33 undesired states

• 1 Week Data Cleaning– UT, Project Manager, Observer, Procedures specialist.

• Validated incident reports and incident investigation findings.

• Causal factors in recent incidents the same Controller behaviour was exhibited during NOSS.

• One of the groups contributed a significant proportion of Undesired States.

What we saw

• 40% of threats were ANSP (organisational)– STAR Clearances, other controllers, unserviceable equipment.

• 60% of threats were Airborne/Environmental– Most Prevalent Restricted Airspace, Airspace Design, pilots.

• Most mismanaged threat - other controllers

• Errors recorded on 77% of observations– 33% equipment/automation, 33% procedural, 25% communication.

• 33 Undesired States– Majority pertaining to inaccurate traffic representation.

What we saw

What we saw• Controller Briefings poor prior to commencement of

shift.

• Handover Takeovers poor, incomplete, not all pertinent operational information conveyed. Checklists not being adhered to.

• Controller Air Situation Display not kept up to date. Too much Human Machine Interface interaction?

• Full readbacks not being obtained from pilots and ATC.

• Inconsistent application of procedures across similar groups.

Lessons Learned.

• Joint Management/Union sponsorship – significant time frame.

• Scheduling of observations with training – ad hoc

• Observer Selection.

• Observer overload.

• Supervision.

• Controller refusals – testing the waters

Tangible

Introduction of new HO/TO checklist on one Group.

Intangible

• Observers adopting practices witnessed during observations, taking them back to their group.

• Increasing skill sets.

What’s Happened to date?

Where to next?

• Brief Board Safety and Environment Committee in December.

• Initiate Safety Change.

• Trial in Tower Units.

• Incorporate into Business Operations.

• Collaborate with airlines.

• Develop Threat and Error Management training program for controllers.

Watch this space!Watch this space!Watch this space!Watch this space!