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2015
Pierre ROSELLINI
ANSP04 ATM Safety Culture Safety Management System
Module 1
Why do we need a Safety Management System ?
- berlingen accident- Reason model
- This presentation on the berlingen accident is not made to judge a state, an organization or men, but to understand what happened.
- We will try to see how a Safety Management System (SMS) would have prevented this accident.
Why do we need a Safety Management System ?berlingen accident
- This accident happened over the territory of the Federal Republic of Germany, July 1, 2002 at 09h35 pm UTC.
- 71 persons were killed.
- On 24 February 2004 the air traffic controller on duty during the accident was murdered by the parent of a victim.
berlingen accident
berlingen accident
- Most of following informations are issued from the Report AX001 May 2004 of the BFU German Federal Bureau of Aircraft Accidents Investigation. - You can find this report at : http://www.bfu-web.de- Search with Uberlingen.
berlingen accident
Search results : 1 Report and 2 Annexes.
berlingen accident : factual informations
- The 2 flights involved in the collision were controlled byACC Zurich.
- The air traffic volume at ACC Zurich is characterized bydifferent traffic flows : transit flights, climbs from airportsand descents to airports.
- This accident happened over the territory of the FederalRepublic of Germany, July 1, 2002 at 09h35 pm UTC.Control of the airspace in this area is delegated to theSwiss Air Navigation Services.
berlingen accident : factual informations
- During the night shift the whole airspace of ACC Zurich had been switched to workstation RP (128,50 MHz).
- On 1 July at 21h the traffic load was low :Tupolev TU154M and Boeing B757-200 on 128,50 MHz.Airbus A320 delayed flight to Friedrichshafen on 119,920MHz.- The meteorolical conditions were good.
- The approach of Friedrichshafen had been switched to workstation RE (119,920 MHz).
berlingen accident : factual informations
- For the night from 1 to 2 July a modification of the upperairspace sectorisation had been planned.The modification work was to start at 9 pm and was tolast about 6 hours.
- Several systems were impacted by the works : Radar data processing, Flight plan data processing, ATS ground-ground telecommunication system.
Main consequences :- No automatic correlation. - Visual Short Term Conflict Alert (STCA) was off.- Direct telephone connection with the other centers
(Karlsruhe, Friedrichshafen ) had to be switched off.
berlingen accident : factual informations
- 2 official instructions regarding these changes wereissued. These instructions described the assignment ofthe new sectors and the procedures to be followed afterthe completion of the sectorisation.
- Others centers (Karlsruhe, Friedrichshafen ) were notinformed of planned work.
- An additional memoradum included a list of systemimpacted by the work. This memoradum wasnt clear andthe information that the ground-ground direct phoneconnection had to be switched off, was missing.
berlingen accident : factual informations
- 10 technicians were scheduled to carry out the plannedwork, about 6 stayed in the control room.
- 1 staff member from the ACC management was there toact as coordinator between controllers and technicians.During the whole time he stayed in close vicinity with thecontroller.
- The controller had not been informed about the tasks ofthe coordinator.
berlingen accident : factual informations
- Both aircrafts are equipped with TCAS (Traffic alert and Collision Avoidance System).
- B757-200 from Bergamo (Italia) to Brussels (Belgium), cargo flight with 2 pilots.
- Tupolev TU154M from Moscow (Russia) to Barcelona (Spain), 9 crew members and 60 passengers.
berlingen accident : factual informations
berlingen accident : chronology the aircrafts
Events in both cockpits.
berlingen accident : chronology Zurich ACC
In accordance with the procedure SMOP (Single MannedOperation Procedure) :- The second controller on duty left the control room atabout 09h15 pm.- The second assistant left the control room at about 09h25 pm.They retired to rest at the lounge.
- Both controllers have reported to duty at 5h50 pm.
- The chief controller was on duty until 09h pm.
berlingen accident : chronology Zurich ACC
09h10 pm : The technicians entered the control room and set to work.
09h18 pm : The optical SCTA was not avalaible.
09h23 pm : The direct telephone lines to the others ACC and airports were no longer avalaible (Unfortunately the switch to the public network was also out of service).
09h34 30s pm : the direct telephone on RP position is OK.
09h34 37s pm : the direct telephone on RE position is OK.
berlingen accident : chronology Aircrafts-ACC
09h21 21s pm : initial call of Boeing 757
09h30 11s pm : initial call of Tupolev 154
09h?? pm : initial call of Airbus A320, delayed flight, approach to Friedrichshafen ; this fligth was unexpected.
09h35 32s pm : collision between Boeing 757 and Tupolev 154.
berlingen accident : analysis
Boeing 757 : When the TCAS issued a RA descend descend the crew acted in accordance with procedures.
berlingen accident : analysis
Tupolev 154 : - The BFU considers the crews qualification and experience to be high.The pilot sitting on the right seat is the chief pilot of the compagny. The crew has received a TCAS training in accordance with the national regulations. The crew has not a practical experience of TCAS.
- The manuel compagny was ambiguous about the priority of RA TCAS.
berlingen accident : analysis
Tupolev 154
At 09h34 56s pm 3 very closed events occurred for the crew :- The instruction of the controller to descent to FL350 has just ended.- The pilot pushed the control column forward (to descent).- An RA climb climb was generated by TCAS. There was a conversation in the cockpit about the RA, butaccording to the compagny manual it was not mandatoryto follow the RA.
berlingen accident : analysis
See and avoid
The apparent object size of an aircraft changes in form of an exponential function during the approach of two aircrafts. The aircraft stays little for a long time then it explodes optically just a few seconds before the collision.
ACC Zurich- When the controllers reported for duty at 05h50 pm they were not aware about the scheduled work. They did not seize the opportunity to read the documents avalaible for the self briefing.- The controller was concentrated on the Airbus approaching Friedrichshafen. He had to move from position RP to position RE. He tried several times to phone to Friedrichshafen but due to work in progress it was not possible. Unfortunately the connection to the public network phone was not avalaible.
berlingen accident : analysis
ACC Zurich
- Single Manned Operation Procedure (SMOP) was not an official procedure but was known and tolerated by the management.
- Priorities had not been evaluated properly by the controller.
ATC Karlsruhe
- Visual Short Term Conflict Alert (STCA) was off.
They tried several times to phone to Zurich ; 2 calls with no response.
berlingen accident : analysis
berlingen accident : analysis
- For TCAS, regulations of the ICAO are in several documents : Annex 2, Annex 10, Doc 8186 PANS-OPS,Doc 4444 PANS-ATM, State letter AN 11/19-02/82.
- Analysis of the BFU has shown that TCAS regulations are not clear enough.
Regulations
James Reason, born in 1938 in England, is a human factors expert.
berlingen accident : Reason model
Regulations
Management
Controllers
Pilots
Equipments
berlingen accident : Reason model
Reason's model : an organization's defenses against failure are modeled as a serie of barriers, represented as plates with holes. The holes in the plates represent weaknesses. The size and the position of the holes in the plate are varying.
When holes in each plate are aligned a collision happens.
berlingen accident : Reason model
Regulations
Management
Controllers
Pilots
Equipments
Collision
berlingen accident : Causes & Reason model
The conflict has not been seen and solved by the ATCO.
The TU154 crew followed the ATC instruction to descend, and continued after the RA TCAS to climb.
Immediate causes :
Collision
Regulations
Management
Controllers
Pilots
Equipments
We can put each cause in a plate. The plates are families of causes.
Other causes :
The management of ACC Zurich did not ensure that during the night all open positions were continuously staffed by controllers.The management of ACC Zurich tolerated for years that during times of low traffic at night only one controller worked (SMOP).The regulations concerning TCAS published by ICAO and by national aviation authorities, were not standardised ; they were incomplete and partially contradictory.
berlingen accident : Causes & Reason model
Collision
Regulations
Management
Controllers
Pilots
Equipments
Due to work in progress :-Optical STCA was off,-Direct phone connections with adjacent centres were off.
No Risk assessment and mitigation for the works. No internal coordination between operationals and technicians.
The written directives concerning the accomplishment of thework did not included explanations about the effects thatwork would have on the availability of technical equipment.
berlingen accident : Causes & Reason model
Collision
Regulations
Management
Controllers
Pilots
Equipments
Due to work in progress :-Optical STCA was off,-Direct phone connections with adjacent centres were off.
No Risk assessment and mitigation for the works. No internal coordination between operationals and technicians.
The written directives concerning the accomplishment of thework did not included explanations about the effects thatwork would have on the availability of technical equipment.
The controllers were obliged to read directives concerning the accomplishment of work. But on the 1st july they did not read these directives.
The ATCO had to work on 2 adjacent positions with 2 different frequencies.
The ATCO was not aware that the optical STCA was off.
berlingen accident : Causes & Reason model
Collision
Regulations
Management
Controllers
Pilots
Equipments
The bypass phone system had a technical defect, so it was impossible to contact Friedrichshafen.
The controller did not detect the conflict between TU154Mand B737-200. During the last 5 minutes before thecollision, the controller has focused its attention on theAirbus A320 on approach with Friedrichshafen.
berlingen accident : Causes & Reason model
Collision
Regulations
Management
Controllers
Pilots
Equipments
berlingen accident : Reason model
Collision
Regulations
Management
Controllers
Pilots
Equipments
To avoid collision we have to delete only 1 hole on 1 plate
berlingen accident : Reason model
Collision
Regulations
Management
Controllers
Pilots
Equipments
1 hole has disappeared in management plate. This plate is certainly the easiest to correct.
X
berlingen accident : Reason model
Collision
Regulations
Management
Controllers
Pilots
Equipments
X
A Safety Management System in ACC has actions on almost all the plates.
Why do we need a Safety Management System ?
END
Module 2SMS Requirements and Implementation
ICAO Annex 19, DOC9859European Requirements.
Policy, Responsability, Priority, Objectives, Competency.
Documentation, External Services.
Survey, Monitoring, Records.
SMS Requirements and Implementation
For Safety Management System we have :- requirements ICAO Annex 19 http://www.icao.int/Pages/default.aspx- requirements European Single Skyhttp://www.skybrary.aero/index.php/Portal:Safety_Regulationshttps://www.eurocontrol.int/
Requirements for European Single Sky are built on ESARRrequirements.They are more explicit and easier to understand than therequirements of Annex 19.
All these requirements are very close.
ICAO Annex 19
- The first edition of Annex 19 (July 2013)was adopted by the council on 25 february2013 and becomes applicable on 14November 2013.- A lot of requirements concern theNational Supervisory Authority (NSA).
- Guidance on the implementation of aSMS is contained in DOC 9859 SafetyManagement Manual.
- Requirements for Air National ServiceProviders (ANSP) are in c4.1.7 and inAppendix 2.
ICAO Annex 19
1. Safety Policy and Objectives
2. Safety Risk Management
3. Safety Assurance
4. Safety Promotion
ICAO Annex 19
There is a personal work in progress in order to understand and to precise each item of Annex 19.In blue you have what has been added.
ICAO Annex 19
1. Safety Policy and Objectives
1.1 Management commitment and responsability1.2 Safety accountabilities.1.3 Appointment of key safety personnel.1.4 Coordination of emergency response planning.1.5 SMS documentation.
ICAO Annex 19
1. Safety Policy and Objectives
1.1. Management commitment and responsabilityCommitment at the highest level1.2 Safety accountabilities.Responsibility at the highest levelResponsibilities of the managerial staff1.3 Appointment of key safety personnel.Responsibilities1.4 Coordination of emergency response planning.Contingency plan in ATC1.5 SMS documentation.Management of SMS documentationManagement of operationnal documentationIdentification of demonstrative elements (records)
ICAO Annex 19
2. Safety Risk Management
2.1 Hazard identification.2.2 Safety risk assessment and mitigation
ICAO Annex 19
2. Safety Risk Management
2.1 Hazard identification.Notification, immediate actions, analysis of eventsProcessing of safety occurrencesProcessing of security occurrencesPlanning tools and resources2.2 Safety Risk Assessment and MitigationSafety studies (changes)Programmed method of interventionMonitoring measures to reduce risk
ICAO Annex 19
3. Safety Assurance
3.1 Safety performance monitoring and measurement.3.2 The management of change.3.3 Continuous improvement of SMS.
ICAO Annex 19
3. Safety Assurance
3.1 Safety performance monitoring and measurement.Monitoring of Indicators 3.2 The management of change.Management of projects3.3 Continuous improvement of SMS.Corrective ActionsAuditsProcess reviewManagement review
ICAO Annex 19
4. Safety Promotion
4.1 Training and education.4.2 Safety communication.
ICAO Annex 19
4. Safety Promotion
4.1 Training and education.SMI trainingCompetency (ATCO, ATSE)4.2 Safety communication.Lesson dissemination
2002-2004.The Eurocontrol SAfety Regulatory Requirements (ESARR) were prepared by Eurocontrol.
European requirements
The European Commission converted these ESARRs into Common Requirements that were published in 2004 (and amended in 2011). It is on the basis of these requirements that the ANSPs of the UE countries have been certified as air navigation service provider in the European Single Sky.
Eurocontrol SAfety Regulatory Requirement (ESARR)
ESARR1 is for NSA ESARR3 is for ANSP
The SMS requirementsare in ESARR3.
Eurocontrol SAfety Regulatory Requirement (ESARR)
Safety Occurrences
ESARR3 is linked to :- ESARR2 for safetyoccurrences,
Competences
- ESARR5 for competencies,
RiskAssessment
and Mitigation
- ESARR4 for riskassessment and mitigation,
Software in ATM
functionalsystems
- ESARR6 for software.
Today :- 1034 2011 Safety Oversight for NSA. - 1035 2011 Common Requirements for ANSP.
European requirements
1034 1035
ICAO Annex 19
1. Safety Policy and Objectives
2. Safety Risk Management
3. Safety Assurance
4. Safety Promotion
EU Requirements
Safety Policy Level
To Achieve Safety
To Ensure Safety
To Promote Safety
ICAO Annex 19 vs EU Requirements
SMS requirements
SMS Requirements
SAFETY POLICY LEVEL
SAFETY MANAGEMENTTO IMPLEMENT A FORMAL AND EXPLICIT SAFETY MANAGEMENT APPROACH
SAFETY RESPONSIBILITYEVERYBODY HAS ANINDIVIDUAL SAFETYRESPONSIBILITY FORHIS/HER OWN ACTION
SAFETY OBJECTIVETO MINIMISE THE ATM CONTRIBUTION TO THE RISK OF AN AIRCRAFT ACCIDENT
SAFETY PRIORITYOVER COMMERCIAL, OPERATIONAL, ENVIRONMENTAL OR SOCIAL PRESSURES
SMS requirements
SAFETY POLICY LEVEL
SAFETY MANAGEMENTTO IMPLEMENT A FORMAL AND EXPLICIT SAFETY MANAGEMENT APPROACH
SAFETY RESPONSIBILITYEVERYBODY HAS ANINDIVIDUAL SAFETYRESPONSIBILITY FORHIS/HER OWN ACTION
SAFETY OBJECTIVETO MINIMISE THE ATM CONTRIBUTION TO THE RISK OF AN AIRCRAFT ACCIDENT
SAFETY PRIORITYOVER COMMERCIAL, OPERATIONAL, ENVIRONMENTAL OR SOCIAL PRESSURES
This requirement means that you have to implement a SMS !
SMS requirements
SAFETY POLICY LEVEL
SAFETY MANAGEMENTTO IMPLEMENT A FORMAL AND EXPLICIT SAFETY MANAGEMENT APPROACH
SAFETY RESPONSIBILITYEVERYBODY HAS ANINDIVIDUAL SAFETYRESPONSIBILITY FOR HIS/HER OWN ACTION
SAFETY OBJECTIVETO MINIMISE THE ATM CONTRIBUTION TO THE RISK OF AN AIRCRAFT ACCIDENT
SAFETY PRIORITYOVER COMMERCIAL, OPERATIONAL, ENVIRONMENTAL OR SOCIAL PRESSURES
Everyone involved in safety and in safety management has responsibilities clearly defined.Everyone must known his responsibilities.
SAFETY RESPONSIBILITYEVERYBODY HAS ANINDIVIDUAL SAFETYRESPONSIBILITY FOR HIS/HER OWN ACTION
Implementation by
SAFETY RESPONSIBILITYEVERYBODY HAS ANINDIVIDUAL SAFETYRESPONSIBILITY FOR HIS/HER OWN ACTION
Implementation by
ATCOs and ATSEPs
SMS requirements
SAFETY POLICY LEVEL
SAFETY MANAGEMENTTO IMPLEMENT A FORMAL AND EXPLICIT SAFETY MANAGEMENT APPROACH
SAFETY RESPONSIBILITYEVERYBODY HAS ANINDIVIDUAL SAFETYRESPONSIBILITY FORHIS/HER OWN ACTION
SAFETY OBJECTIVETO MINIMISE THE ATM CONTRIBUTION TO THE RISK OF AN AIRCRAFT ACCIDENT
SAFETY PRIORITYOVER COMMERCIAL, OPERATIONAL, ENVIRONMENTAL OR SOCIAL PRESSURES
SAFETY PRIORITYOVER COMMERCIAL, OPERATIONAL, ENVIRONMENTAL OR SOCIAL PRESSURES
Implementation bySAFETY PRIORITYOVER COMMERCIAL, OPERATIONAL, ENVIRONMENTAL OR SOCIAL PRESSURES
We can consider that an ANSP is surrounded by barriers.ANSP
Operational
Implementation bySAFETY PRIORITYOVER COMMERCIAL, OPERATIONAL, ENVIRONMENTAL OR SOCIAL PRESSURES
If you put more pressure on one side
ANSP
Operational
you must put less pressure on the others.
Implementation bySAFETY PRIORITYOVER COMMERCIAL, OPERATIONAL, ENVIRONMENTAL OR SOCIAL PRESSURES
Example of commercial pressure. all airlines want to arrive in Paris around 08 am.
Implementation bySAFETY PRIORITYOVER COMMERCIAL, OPERATIONAL, ENVIRONMENTAL OR SOCIAL PRESSURES
Map of the routes and sectors around Paris.Each sector has a maximum number of aircrafts that can be handled at same time.So it is not possible to accept that too much aircrafts arrive in Paris airport at same time for safety reasons.
Implementation bySAFETY PRIORITYOVER COMMERCIAL, OPERATIONAL, ENVIRONMENTAL OR SOCIAL PRESSURES
1. Strategic.Twice a year allocate slots for an optimal use of airport resources in respect with the constraints,Monitor the proper use of slots allocated to airlines.
2. Tactical.The Network Manager Operations Centre in Brussels can modify time of departure of flights if the maximum capacity on an area is reached.
Because safety is the most important item, in order to avoid to have too many flights in Paris at 8h am :
Implementation bySAFETY PRIORITYOVER COMMERCIAL, OPERATIONAL, ENVIRONMENTAL OR SOCIAL PRESSURES
ANSP
Operational
- In accordance with this requirement you must never accept to put less pressure on safety barrier.- Your policy must explain this.- You must apply your policy.
Extract of policy of the French ANSP.The policy or strategy of DSNA is defined by the Director of the DSNA under the authority of the Director General of Civil Aviation (DGCA) and related services, to achieve the objectives of the LOLF.It is materialized by a set of strategic directions defined in the 5 years plan and precised in each annual plan At this end we give priority to the following strategic axes:1) Ensure a high level of safety and security of air navigation2) Controlling the environmental impact of air traffic3) Improve delays.4) Improve the economic efficiency of air navigation services5) Participate in European construction 6) Consider the needs of general aviation in the establishment procedures and airspace structures.I rely on the involvement of all staff to address these objectives at all levels, in order to strengthen the unit and the image of DSNA.I will ensure its implementation and its effectiveness.s
SMS requirements
SAFETY POLICY LEVEL
SAFETY MANAGEMENTTO IMPLEMENT A FORMAL AND EXPLICIT SAFETY MANAGEMENT APPROACH
SAFETY RESPONSIBILITYEVERYBODY HAS ANINDIVIDUAL SAFETYRESPONSIBILITY FORHIS/HER OWN ACTION
SAFETY OBJECTIVETO MINIMISE THE ATM CONTRIBUTION TO THE RISK OF AN AIRCRAFT ACCIDENT
SAFETY PRIORITYOVER COMMERCIAL, OPERATIONAL, ENVIRONMENTAL OR SOCIAL PRESSURES
Implementation by
That requirement means that you must define quantitative and/or qualitative objectives.
SAFETY OBJECTIVETO MINIMISE THE ATM CONTRIBUTION TO THE RISK OF AN AIRCRAFT ACCIDENT
Very often the quantitative objectives are linked to indicators.
Objectives can be defined in the policy or in the action plan.
Extract of policy of the French ANSP.The policy or strategy of DSNA is defined by the Director of the DSNA under the authority of the Director General of Civil Aviation (DGCA) and related services, to achieve the objectives of the LOLF.It is materialized by a set of strategic directions defined in the 5 years plan and precised in each annual plan At this end we give priority to the following strategic axes:1) Ensure a high level of safety and security of air navigation2) Controlling the environmental impact of air traffic3) Improve delays.4) Improve the economic efficiency of air navigation services5) Participate in European construction 6) Consider the needs of general aviation in the establishment procedures and airspace structures.I rely on the involvement of all staff to address these objectives at all levels, in order to strengthen the unit and the image of DSNA.I will ensure its implementation and its effectiveness.
SMS requirements
TO ACHIEVE SAFETYMEANS FOR ACHIEVING HIGH SAFETY STANDARDS
AN APPROPRIATE ORGANISATION SYSTEMATIC ACTIONS
SMS DOCUMENTATION THE SMS IS A DOCUMENTED SYSTEM ARISING FROM A SAFETY POLICY
COMPETENCYSTAFF TRAINED, MOTIVATED AND COMPETENT
SAFETY MANAGEMENT RESPONSIBILITY SAFETY MANAGEMENT FUNCTION WITHIN THE ORGANISATION
EXTERNAL SERVICES DEALING WITH EXTERNALLY PROVIDED SERVICES
QUANTITATIVE SAFETY LEVELS DERIVING QUANTITATIVE LEVELS WHEREVER PRACTICABLE
SAFETY OCCURRENCES ATM OPERATIONAL OR TECHNICAL OCCURRENCES ARE INVESTIGATED INTERNALLY
RISK ASSESSMENT AND MITIGATION THE SAFETY OF NEW SYSTEMS AND CHANGES IS TO BE DEMONSTRATED USING A RISK BASED APPROACH.RISK IS ASSESSED AND MITIGATED.
SMS requirements
TO ACHIEVE SAFETYMEANS FOR ACHIEVING HIGH SAFETY STANDARDS
AN APPROPRIATE ORGANISATION SYSTEMATIC ACTIONS
SMS DOCUMENTATION THE SMS IS A DOCUMENTED SYSTEM ARISING FROM A SAFETY POLICY
COMPETENCYSTAFF TRAINED, MOTIVATED AND COMPETENT
SAFETY MANAGEMENT RESPONSIBILITY SAFETY MANAGEMENT FUNCTION WITHIN THE ORGANISATION
EXTERNAL SERVICES DEALING WITH EXTERNALLY PROVIDED SERVICES
QUANTITATIVE SAFETY LEVELS DERIVING QUANTITATIVE LEVELS WHEREVER PRACTICABLE
SAFETY OCCURRENCES ATM OPERATIONAL OR TECHNICAL OCCURRENCES ARE INVESTIGATED INTERNALLY
RISK ASSESSMENT AND MITIGATION THE SAFETY OF NEW SYSTEMS AND CHANGES IS TO BE DEMONSTRATED USING A RISK BASED APPROACH.RISK IS ASSESSED AND MITIGATED.
COMPETENCYSTAFF TRAINED, MOTIVATED AND COMPETENT
- The overall safety objective is to ensure the competence of personnel responsible for safety related tasks within the provision of ATM services.
- Air Traffic Controller (ATCO) and Air Traffic Safety Engineers Personnel (ATSEP) are mainly concerned by this requirement.
Requirements for ATCO competency.
ICAOAnnex 1 and DOC 9379.
European requirementsRegulation (EU) 2015/340.
Implementation byCOMPETENCYSTAFF TRAINED, MOTIVATED AND COMPETENTATCO
To be allowed to work on a position, ATCOs must have a valid licence issued by the National Supervisory Authority.
To obtain the licence (initial training) :- Training in ENAC.- Training in ACC or Airport. - On job training.- Medical certificate.
Implementation byCOMPETENCYSTAFF TRAINED, MOTIVATED AND COMPETENTATCO
To maintain the licence (continuing training) :- Evaluation and individual training plan.- Proficiency in English. - Medical certificate.- Annual number of hours worked.
Implementation byCOMPETENCYSTAFF TRAINED, MOTIVATED AND COMPETENT
A database is used to monitor the competency of ATCOs.For each ATCO all the trainings done are recorded in this database.
ATCO
To manage, monitor and organize all these trainings we have a dedicated subdivision.
Paris ACC :- 550 ATCOs- Among them 100 ATCOs are in training.
OPS Division : Training Subdivision
OPS Division
SubdivisionStudies
SubdivisionTraining
SubdivisionSafety
Aera East12 teams of 18 ATCO
Aera West12 teams of 18 ATCO
FMP FISAlert
SubdivisionATCO OPS Training
ChiefDeputyATCOEngineers
Implementation byCOMPETENCYSTAFF TRAINED, MOTIVATED AND COMPETENTATCO
Planning Paris ACC
IndividualTraining
English
Instructors
Chief Controller
UnitsContinuingTraining 1
ContinuingTraining 2
Requirements for ATSEP competency.
ICAO.- ICAO Annex 1.- SARPS published in ICAO Annex 10 and guidance material in ICAO Doc 7192 - AN/857 Part E2.
European requirements.- ESARR 5 Section3 - Requirements for Engineering and Technical Personnel Undertaking Operational Safety Related Tasks.- Regulation 1035/2011 Annex II section 3.3 (idem ESARR5).
Implementation byCOMPETENCYSTAFF TRAINED, MOTIVATED AND COMPETENTATSEP
Implementation byCOMPETENCYSTAFF TRAINED, MOTIVATED AND COMPETENTATSEP
CNS-ATM EnergyCommunication Electrical engineeringNavigation Air conditioningSurveillanceData processingSupervision and monitoring systems
To be allowed to work on a position, ATSEPs must have a valid licence issued by the National Supervisory Authority.
SubdivisionTraining
Paris ACC :- 80 ATSEPs- Among them about 8 ATSEPs are in training.
Training
ChiefDeputyATSEPInstructors
Technical Division : Training SubdivisionOPS
Division
SubdivisionStudies
SubdivisionSafety
Aera East12 teams of 18 ATCO
Aera West12 teams of 18 ATCO
FMP FISAlert
SubdivisionATCO OPS
SMS requirements
TO ACHIEVE SAFETYMEANS FOR ACHIEVING HIGH SAFETY STANDARDS
AN APPROPRIATE ORGANISATION SYSTEMATIC ACTIONS
SMS DOCUMENTATION THE SMS IS A DOCUMENTED SYSTEM ARISING FROM A SAFETY POLICY
COMPETENCYSTAFF TRAINED, MOTIVATED AND COMPETENT
SAFETY MANAGEMENT RESPONSIBILITY SAFETY MANAGEMENT FUNCTION WITHIN THE ORGANISATION
EXTERNAL SERVICES DEALING WITH EXTERNALLY PROVIDED SERVICES
QUANTITATIVE SAFETY LEVELS DERIVING QUANTITATIVE LEVELS WHEREVER PRACTICABLE
SAFETY OCCURRENCES ATM OPERATIONAL OR TECHNICAL OCCURRENCES ARE INVESTIGATED INTERNALLY
RISK ASSESSMENT AND MITIGATION THE SAFETY OF NEW SYSTEMS AND CHANGES IS TO BE DEMONSTRATED USING A RISK BASED APPROACH.RISK IS ASSESSED AND MITIGATED.
Operational Documentation ATCO ManualsATSEP Manuals
Technical documentation
Records: Minutes management review, ACAP, Dashboards, Safety occurrences,
Reports of audits, Strips, Data radar , Flight plan data
SMSManual
Procedures: Audits, Documentation, Records, Corrective Actions,
Management review
Mapping, Process, Activites
SMS DOCUMENTATION THE SMS IS A DOCUMENTED SYSTEM ARISING FROM A SAFETY POLICY
The documentation of the SMS can be represented bya five floors pyramid.
Implementation by
SESW
5 ACC
Headquarters
WE
N
BrestCDG & Orly Strasbourg
Lyon
Nice
MarseilleToulouse
Bordeaux
West IndiesGuiana
IndianOcean
11 Airports
Lille
AIS CESNAC
CESNAC = Centralised Air
Navigation SystemsOperations Centre
SMS DOCUMENTATION THE SMS IS A DOCUMENTED SYSTEM ARISING FROM A SAFETY POLICY
Implementation by
The Paris ACCs Manual explains how the SMS requirements are implemented.
Implementation by
SMS DOCUMENTATION THE SMS IS A DOCUMENTED SYSTEM ARISING FROM A SAFETY POLICY
Anything you write in the SMS manual must be done and demonstrated. It is a new layer of requirements.
Implementation bySMS DOCUMENTATION THE SMS IS A DOCUMENTED SYSTEM ARISING FROM A SAFETY POLICY
So avoid writing too much.
We can use ISO 9001 (quality) tools in order to explain in a procedure how we manage the documentation.
Implementation bySMS DOCUMENTATION THE SMS IS A DOCUMENTED SYSTEM ARISING FROM A SAFETY POLICY
We can identify different families of documents. For each family we define management rules.
Who write, who verifie, who approve ? What is the current version ? Paper or electronic document ? Where is the document of reference ?
With such a procedure its very easy to build an electronic documentation.
Implementation bySMS DOCUMENTATION THE SMS IS A DOCUMENTED SYSTEM ARISING FROM A SAFETY POLICY
Implementation bySMS DOCUMENTATION THE SMS IS A DOCUMENTED SYSTEM ARISING FROM A SAFETY POLICY
OperationalDivision
All the documentation has been converted in pdf files.
The procedure PRO_E_OPR describes the management of the operational documentation.
With these pdf files an intranet site has been implemented.
The procedure PRO_INST_OPR describes the management of the training documentation.
Implementation bySMS DOCUMENTATION THE SMS IS A DOCUMENTED SYSTEM ARISING FROM A SAFETY POLICY
ATCOs documentation.
OperationalDivision
Implementation bySMS DOCUMENTATION THE SMS IS A DOCUMENTED SYSTEM ARISING FROM A SAFETY POLICY
ATCO Training
OperationalDivision
Implementation bySMS DOCUMENTATION THE SMS IS A DOCUMENTED SYSTEM ARISING FROM A SAFETY POLICY
TechnicalDivision
A specific tool SIAM has been implemented. The technical documentation is stored on SIAM.
The procedure PRO_T_OPR describes the management of the technical documentation.
This procedure has been elaborated by a working group :Chief of the Technical Division, Chief of the safetysubdivision + deputy, Chief of radar subdivision, 10ATSEPs.
Implementation bySMS DOCUMENTATION THE SMS IS A DOCUMENTED SYSTEM ARISING FROM A SAFETY POLICY
TechnicalDivision
TechnicalDivision
Implementation bySMS DOCUMENTATION THE SMS IS A DOCUMENTED SYSTEM ARISING FROM A SAFETY POLICY
Form for operational instruction (subdivision)
TechnicalDivision
Implementation bySMS DOCUMENTATION THE SMS IS A DOCUMENTED SYSTEM ARISING FROM A SAFETY POLICY
Form for operational instruction (division)
TechnicalDivision
Implementation bySMS DOCUMENTATION THE SMS IS A DOCUMENTED SYSTEM ARISING FROM A SAFETY POLICY
1 MISO to implement
2 MISO to verify
3 Feedback in progress
4 Corrective Actions in progress
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Implementation bySMS DOCUMENTATION THE SMS IS A DOCUMENTED SYSTEM ARISING FROM A SAFETY POLICY
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Implementation bySMS DOCUMENTATION THE SMS IS A DOCUMENTED SYSTEM ARISING FROM A SAFETY POLICY
SMS requirements
TO ACHIEVE SAFETYMEANS FOR ACHIEVING HIGH SAFETY STANDARDS
AN APPROPRIATE ORGANISATION SYSTEMATIC ACTIONS
SMS DOCUMENTATION THE SMS IS A DOCUMENTED SYSTEM ARISING FROM A SAFETY POLICY
COMPETENCYSTAFF TRAINED, MOTIVATED AND COMPETENT
SAFETY MANAGEMENT RESPONSIBILITY SAFETY MANAGEMENT FUNCTION WITHIN THE ORGANISATION
EXTERNAL SERVICES DEALING WITH EXTERNALLY PROVIDED SERVICES
QUANTITATIVE SAFETY LEVELS DERIVING QUANTITATIVE LEVELS WHEREVER PRACTICABLE
SAFETY OCCURRENCES ATM OPERATIONAL OR TECHNICAL OCCURRENCES ARE INVESTIGATED INTERNALLY
RISK ASSESSMENT AND MITIGATION THE SAFETY OF NEW SYSTEMS AND CHANGES IS TO BE DEMONSTRATED USING A RISK BASED APPROACH.RISK IS ASSESSED AND MITIGATED.
SAFETY MANAGEMENT RESPONSIBILITY SAFETY MANAGEMENT FUNCTION WITHIN THE ORGANISATION
It means that :- You must have identified a safety management function with responsibility for development and maintenance of the safety management system.- This function must be accountable directly to the highest organisational level.- This function must be independant of the operational management.
SAFETY MANAGEMENT RESPONSIBILITY SAFETY MANAGEMENT FUNCTION WITHIN THE ORGANISATION
A dedicated organization has been identified and created at the national level.
A team called MSQS (french acronym, it means team in charge of the Safety, Security) is directly linked the the Director of the french ANSP.
Implementation by
SAFETY MANAGEMENT RESPONSIBILITY SAFETY MANAGEMENT FUNCTION WITHIN THE ORGANISATION
Implementation by
Planning & StrategieSubdirectorate
Human ResourcesSubdirectorate
FinanceSubdirectorate
The Management of Safety, Security,
Quality Mission
The EnvironmentMission
French ANSP Director
French ANSP Headquarters
SAFETY MANAGEMENT RESPONSIBILITY SAFETY MANAGEMENT FUNCTION WITHIN THE ORGANISATION
Implementation by
A dedicated function has been identified and created in each entity (ACC and Airports).
This function called RSMS (french acronym it means responsible of the SMS) is directly linked to the chief of the entity.
French ANSP : A RSMS can be engineer, ATCO or ATSEP.
SAFETY MANAGEMENT RESPONSIBILITY SAFETY MANAGEMENT FUNCTION WITHIN THE ORGANISATION
Implementation by
OperationsDivision
TechnicalDivision
AdministrativeDivision
ACC or AirportChief
ACC or Airport Organization
Deputy RSMS
SESW
5 ACC
HeadquartersMSQS
WE
NBrestCDG & Orly Strasbourg
Lyon
Nice
MarseilleToulouse
Bordeaux
West IndiesGuiana
IndianOcean
11 Airports
Lille
AIS CESNAC
CESNAC = Centralised Air
Navigation SystemsOperations Centre
SAFETY MANAGEMENT RESPONSIBILITY SAFETY MANAGEMENT FUNCTION WITHIN THE ORGANISATION
Implementation by
RSMS
RSMSRSMS RSMS
RSMS
RSMS
RSMS
RSMS
RSMS
RSMS
RSMS RSMS
RSMS
RSMS
RSMS RSMS
RSMS
RSMS
Links betweenMission and RSMS for mutualization.
SMS requirements
TO ACHIEVE SAFETYMEANS FOR ACHIEVING HIGH SAFETY STANDARDS
AN APPROPRIATE ORGANISATION SYSTEMATIC ACTIONS
SMS DOCUMENTATION THE SMS IS A DOCUMENTED SYSTEM ARISING FROM A SAFETY POLICY
COMPETENCYSTAFF TRAINED, MOTIVATED AND COMPETENT
SAFETY MANAGEMENT RESPONSIBILITY SAFETY MANAGEMENT FUNCTION WITHIN THE ORGANISATION
EXTERNAL SERVICES DEALING WITH EXTERNALLY PROVIDED SERVICES
QUANTITATIVE SAFETY LEVELS DERIVING QUANTITATIVE LEVELS WHEREVER PRACTICABLE
SAFETY OCCURRENCES ATM OPERATIONAL OR TECHNICAL OCCURRENCES ARE INVESTIGATED INTERNALLY
RISK ASSESSMENT AND MITIGATION THE SAFETY OF NEW SYSTEMS AND CHANGES IS TO BE DEMONSTRATED USING A RISK BASED APPROACH.RISK IS ASSESSED AND MITIGATED.
EXTERNAL SERVICES DEALING WITH EXTERNALLY PROVIDED SERVICES
This requirement means : you must check, survey the external services that have a link with safety.
We have to define what are external services.
EXTERNAL SERVICES DEALING WITH EXTERNALLY PROVIDED SERVICES
According to the Letter of Agrement (LOA) we can say that for the German ANSP, the Swiss ANSP is an external service provider.
Implementation by
Remember when we talked about berlingen accident :This accident happened over the territory of the FederalRepublic of Germany, July 1, 2002 at 09h35 pm UTC.Control of the airspace in this area is delegated to the Swiss Air Navigation Services.
EXTERNAL SERVICES DEALING WITH EXTERNALLY PROVIDED SERVICES
French ANSP has identified a list of suppliers and external services that can have an impact on safety.
Implementation by
Key elements of the list of Paris ACC:- Energy.- Air conditioning.- Fire Detection.- Telecommunications.- Cleaning the operational room.- Cleaning technical rooms.- Training in English.
EXTERNAL SERVICES DEALING WITH EXTERNALLY PROVIDED SERVICES
Implementation by
External services Supplier Contract Date &DurationResponsible
for monitoringMaintenance of
generator sets (fuel) SDMOS5204 14504
01.01.125 years
Chief of energy subdivision
Impact on SafetySafety objectives
for supplier (contract) Others Safety barriers
Major.Energy :1 External (EDF)2 Generator sets (fuel)3 Batteries (4h max)
- 2 preventive interventions by year.- Call : intervention within 4 hours.
- 2 generator sets.- SDMO supplier can be helped by local technicians.
EXTERNAL SERVICES DEALING WITH EXTERNALLY PROVIDED SERVICES
Implementation by
External services Supplier Contract Date &DurationResponsible
for monitoring
Fire detection SICLI 11/07 10.12.075 yearsChief of
administrative division
Impact on SafetySafety objectives
for supplier (contract) Others Safety barriersMajor.- Risk of late detection of a fire - False alarms.
- 2 preventive interventions by year.- Call : intervention within 4 hours.- All the be fire detectors must changed within 4 years.
- 2 generator sets.- SDMO supplier can be helped by local technicians.
SMS requirements
TO ACHIEVE SAFETYMEANS FOR ACHIEVING HIGH SAFETY STANDARDS
AN APPROPRIATE ORGANISATION SYSTEMATIC ACTIONS
SMS DOCUMENTATION THE SMS IS A DOCUMENTED SYSTEM ARISING FROM A SAFETY POLICY
COMPETENCYSTAFF TRAINED, MOTIVATED AND COMPETENT
SAFETY MANAGEMENT RESPONSIBILITY SAFETY MANAGEMENT FUNCTION WITHIN THE ORGANISATION
EXTERNAL SERVICES DEALING WITH EXTERNALLY PROVIDED SERVICES
QUANTITATIVE SAFETY LEVELS DERIVING QUANTITATIVE LEVELS WHEREVER PRACTICABLE
SAFETY OCCURRENCES ATM OPERATIONAL OR TECHNICAL OCCURRENCES ARE INVESTIGATED INTERNALLY
RISK ASSESSMENT AND MITIGATION THE SAFETY OF NEW SYSTEMS AND CHANGES IS TO BE DEMONSTRATED USING A RISK BASED APPROACH.RISK IS ASSESSED AND MITIGATED.
QUANTITATIVE SAFETY LEVELS DERIVING QUANTITATIVE LEVELS WHEREVER PRACTICABLE
Based on quantitative risk assessment EUROCONTROL has established in ESARR4 an overall safety performance target for ATM in the ECAC region - the maximum tolerableprobability of ATM directly contributing to an accident of a commercial air transport aircraft shall not be greater than1.55 x 10-8 per flight hour.
According to ICAO DOC 9859 Safety Management manual, Whenever quantitative safety performance targets are set, it must be possible to measure, or estimate, the achieved level of safety in quantitative terms. Use of quantitative data helps clarify most decisions and should be used where available.
SMS requirements
TO ACHIEVE SAFETYMEANS FOR ACHIEVING HIGH SAFETY STANDARDS
AN APPROPRIATE ORGANISATION SYSTEMATIC ACTIONS
SMS DOCUMENTATION THE SMS IS A DOCUMENTED SYSTEM ARISING FROM A SAFETY POLICY
COMPETENCYSTAFF TRAINED, MOTIVATED AND COMPETENT
SAFETY MANAGEMENT RESPONSIBILITY SAFETY MANAGEMENT FUNCTION WITHIN THE ORGANISATION
EXTERNAL SERVICES DEALING WITH EXTERNALLY PROVIDED SERVICES
QUANTITATIVE SAFETY LEVELS DERIVING QUANTITATIVE LEVELS WHEREVER PRACTICABLE
SAFETY OCCURRENCES ATM OPERATIONAL OR TECHNICAL OCCURRENCES ARE INVESTIGATED INTERNALLY
RISK ASSESSMENT AND MITIGATION THE SAFETY OF NEW SYSTEMS AND CHANGES IS TO BE DEMONSTRATED USING A RISK BASED APPROACH.RISK IS ASSESSED AND MITIGATED.
SAFETY OCCURRENCES ATM OPERATIONAL OR TECHNICAL OCCURRENCES ARE INVESTIGATED INTERNALLY
Tuesday 26th may, 13h30-15h
MODULE 4Safety Occurrences
Wednesday 27th may, 09h-10h30h and 10h45-12h15.
SMS requirements
TO ACHIEVE SAFETYMEANS FOR ACHIEVING HIGH SAFETY STANDARDS
AN APPROPRIATE ORGANISATION SYSTEMATIC ACTIONS
SMS DOCUMENTATION THE SMS IS A DOCUMENTED SYSTEM ARISING FROM A SAFETY POLICY
COMPETENCYSTAFF TRAINED, MOTIVATED AND COMPETENT
SAFETY MANAGEMENT RESPONSIBILITY SAFETY MANAGEMENT FUNCTION WITHIN THE ORGANISATION
EXTERNAL SERVICES DEALING WITH EXTERNALLY PROVIDED SERVICES
QUANTITATIVE SAFETY LEVELS DERIVING QUANTITATIVE LEVELS WHEREVER PRACTICABLE
SAFETY OCCURRENCES ATM OPERATIONAL OR TECHNICAL OCCURRENCES ARE INVESTIGATED INTERNALLY
RISK ASSESSMENT AND MITIGATION THE SAFETY OF NEW SYSTEMS AND CHANGES IS TO BE DEMONSTRATED USING A RISK BASED APPROACH.RISK IS ASSESSED AND MITIGATED.
Thursday 28th may 09h-10h30.
RISK ASSESSMENT AND MITIGATION THE SAFETY OF NEW SYSTEMS AND CHANGES IS TO BE DEMONSTRATED USING A RISK BASED APPROACH.RISK IS ASSESSED AND MITIGATED.
MODULE 6 Risk assessment
and Mitgation
SMS requirements
TO ENSURE SAFETYMEANS FOR PROVIDING ASSURANCE THAT RISKS ARE BEING PROPERLY MANAGED
SYSTEMATIC ACTIONSCONCERNING THE STEADY STATE
DOCUMENTING SYSTEMATIC ACTIONS AND CHANGES
SAFETY SURVEYS SAFETY HAS TO BE VERIFIED INTERNALLY AND CONTINUOUSLY
SAFETY MONITORING CONTINUOUS MONITORING AND ANALYSIS OF SAFETY INDICATORS
RISK ASSESSMENT AND MITIGATION DOCUMENTATION THE RESULTS OF RISK ASSESSMENT AND MITIGATION PROCESSES ARE DOCUMENTED THROUGHOUT THE SYSTEM LIFECYCLE
SAFETY RECORDS RECORDS ARE PRODUCED AND MAINTAINED THROUGHOUT THE SMS OPERATION
SMS requirements
TO ENSURE SAFETYMEANS FOR PROVIDING ASSURANCE THAT RISKS ARE BEING PROPERLY MANAGED
SYSTEMATIC ACTIONSCONCERNING THE STEADY STATE
DOCUMENTING SYSTEMATIC ACTIONS AND CHANGES
SAFETY SURVEYS SAFETY HAS TO BE VERIFIED INTERNALLY AND CONTINUOUSLY
SAFETY MONITORING CONTINUOUS MONITORING AND ANALYSIS OF SAFETY INDICATORS
RISK ASSESSMENT AND MITIGATION DOCUMENTATION THE RESULTS OF RISK ASSESSMENT AND MITIGATION PROCESSES ARE DOCUMENTED THROUGHOUT THE SYSTEM LIFECYCLE
SAFETY RECORDS RECORDS ARE PRODUCED AND MAINTAINED THROUGHOUT THE SMS OPERATION
Implementation bySAFETY SURVEYS SAFETY HAS TO BE VERIFIED INTERNALLY AND CONTINUOUSLY
Internal auditors are trained by an approved organization.
Internal auditors must done at least 1 audit per year.
The procedure Internal Audits describes how are realized the internal audits.
Each year a program of internal audits is planned and realized.
Implementation bySAFETY SURVEYS SAFETY HAS TO BE VERIFIED INTERNALLY AND CONTINUOUSLY
External Audits, done by DSAC (french NSA), in order to certify the SMS of DSNA (french ANSP).
Who PeriodicityACC (5) 3 years
Main Airports (11) 2 yearsHeadquarters Each year
Headquarters, ACC and Airports are audited like mentionned below :
Implementation bySAFETY SURVEYS SAFETY HAS TO BE VERIFIED INTERNALLY AND CONTINUOUSLY
2006 DSNA obtained the certificate of ANSP issued by the DSAC. The certificate ended in 2010.2010 Renewal the certificate, valid until 2016.
Monitoring by DSAC : - Audits. - Monitoring of security events.- Monitoring changes and safety records.- Monitoring the performance.
DSAC performs regular coordination with DSNA.
SMS requirements
TO ENSURE SAFETYMEANS FOR PROVIDING ASSURANCE THAT RISKS ARE BEING PROPERLY MANAGED
SYSTEMATIC ACTIONSCONCERNING THE STEADY STATE
DOCUMENTING SYSTEMATIC ACTIONS AND CHANGES
SAFETY SURVEYS SAFETY HAS TO BE VERIFIED INTERNALLY AND CONTINUOUSLY
SAFETY MONITORING CONTINUOUS MONITORING AND ANALYSIS OF SAFETY INDICATORS
RISK ASSESSMENT AND MITIGATION DOCUMENTATION THE RESULTS OF RISK ASSESSMENT AND MITIGATION PROCESSES ARE DOCUMENTED THROUGHOUT THE SYSTEM LIFECYCLE
SAFETY RECORDS RECORDS ARE PRODUCED AND MAINTAINED THROUGHOUT THE SMS OPERATION
Implementation by
In french ACC or Airports safety indicators are built and controlled by dedicated teams (Safety subdivisions) then analysed during several periodic meetings.
SAFETY MONITORING CONTINUOUS MONITORING AND ANALYSIS OF SAFETY INDICATORS
For each meeting we have a safety dashboard.
Dashboard
Topic Results TrendSafetyTrafficDelay
Technical
Summary
Managers need a dashboard for monitoring the main indicators.
Definitions : Losses of separation with 50%, 70%, 80%, 100%
NM
ft
Inside red rectangle we are 50% under the minimum of separation, inside the orange 70%, inside the yellow 80% and inside the blue 100%.
Dashboard : safety indicator
0,35
0,40
0,45
0,50
0,55
0,60
Losses of separation per 100 000 flights
Losses of separation below 70% of the minimum radar separation.French ACC minimum radar separation :- Vertical 1000 ft.- Horizontal 5NM.
Dashboard : safety indicator
0,35
0,40
0,45
0,50
0,55
0,60
Losses of separation per 100 000 flights
HN70 Janv Fvr Mars Avr Mai Juin Juil Aot Sept Oct Nov Dc Total
Evolution annuelle 12 mois glissants
2007 1 1 1 0 0 2 1 0 0 2 0 0 8 0,612008 0 0 1 1 0 2 0 0 1 1 0 1 72009 0 0 0 1 1 0 0 1 1 4
0,000,100,200,300,400,500,600,700,800,901,00
Losses of separation per 100 000 flights
A graph is subjective. These 2 graphs are the same but have different scales.It is useful to present the data in a table.
Dashboard : safety indicator
Resolution Advisory Traffic Alert Collision Avoidance System (RA TCAS).
0,000,100,200,300,400,500,600,700,800,901,00
RA TCAS per 100 000 flights
Dashboard : Delays indicator
0
20000
40000
60000
80000
100000
120000
140000
160000
mi n
u te s
Delays for xxxx ACC Dlais 07/08Dlais 08/09
In a dashboard you must explain the peaks or the anomalies.
Meteorogical conditions
ATCO strike
Dashboard : Technical indicators
Dashboard : Technical indicators
Event with severity b :Frequency 128,140 permanent emission by aircraft from11h24 to 11h30 am.
This event has been classified with severity b : it is a partial inability to provide safe ATM services.In this case only the frequency 128,140 isconcerned.
Dashboard : Technical indicators
Events on telecom leased lines.
Implementation bySAFETY MONITORING CONTINUOUS MONITORING AND ANALYSIS OF SAFETY INDICATORS
SubdivisionSafety1 chief1 Deputy4 ATCO and assistants
When Who
Daily
Chief Division OPS, deputy, chiefs subd
Monthly
OPS Division
SubdivisionSafety1 chief1 Deputy2 ATSEP
When Who
Daily
Chief Technical Division, deputy, chiefs subd
Weekly
Technical Division
DirectionWhen Who
Chief, Deputy, RSMS,Chiefs of divisions, deputies
Weekly
SMS requirements
TO ENSURE SAFETYMEANS FOR PROVIDING ASSURANCE THAT RISKS ARE BEING PROPERLY MANAGED
SYSTEMATIC ACTIONSCONCERNING THE STEADY STATE
DOCUMENTING SYSTEMATIC ACTIONS AND CHANGES
SAFETY SURVEYS SAFETY HAS TO BE VERIFIED INTERNALLY AND CONTINUOUSLY
SAFETY MONITORING CONTINUOUS MONITORING AND ANALYSIS OF SAFETY INDICATORS
RISK ASSESSMENT AND MITIGATION DOCUMENTATION THE RESULTS OF RISK ASSESSMENT AND MITIGATION PROCESSES ARE DOCUMENTED THROUGHOUT THE SYSTEM LIFECYCLE
SAFETY RECORDS RECORDS ARE PRODUCED AND MAINTAINED THROUGHOUT THE SMS OPERATION
SAFETY RECORDS RECORDS ARE PRODUCED AND MAINTAINED THROUGHOUT THE SMS OPERATION
Implementation by
Safety records are the result of an activity (indicators) or the proof that an activity has been performed (minutes of a meeting).
MAINTAINED THROUGHOUT THE SMS OPERATION
y records he result of ctivity cators) or roof that an ty has been rmed
utes of a ing). Operational Documentation
ATCO ManualsATSEP Manuals
Technical documentation
Records: Minutes management review, ACAP, Dashboards, Safety occurrences,
Reports of audits, Strips, Data radar , Flight plan data
SMSManual
Procedures : Audits, Documentation, Records, Corrective Actions,
Management review
Mapping, Process, Activites
RISK ASSESSMENT AND MITIGATION DOCUMENTATION THE RESULTS OF RISK ASSESSMENT AND MITIGATION PROCESSES ARE DOCUMENTED THROUGHOUT THE SYSTEM LIFECYCLE
SAFETY RECORDS RECORDS ARE PRODUCED AND MAINTAINED THROUGHOUT THE SMS OPERATION
RISK ASSESSMENT AND MITIGATION DOCUMENTATION THE RESULTS OF RISK ASSESSMENT AND MITIGATION PROCESSES ARE DOCUMENTED THROUGHOUT THE SYSTEM LIFECYCLE
Implementation by
Paris ACC is using an ISO tool : a documented procedure for records. This documented procedure defines several items : identification, storage, protection, retrieval, and retention of records.
SAFETY RECORDS RECORDS ARE PRODUCED AND MAINTAINED THROUGHOUT THE SMS OPERATION
RISK ASSESSMENT AND MITIGATION DOCUMENTATION THE RESULTS OF RISK ASSESSMENT AND MITIGATION PROCESSES ARE DOCUMENTED THROUGHOUT THE SYSTEM LIFECYCLE
Implementation by
Record Acces Who Where Support Duration Archivage
Minutes of management
reviewFree
RSMSG:\Dir_CRNA\SMQS\revues Electronic 3 years 5 years
Audit reportsFree
RSMSG:\Dir_CRNA\SMQS\audits Electronic 3 years 5 years
LOAs FreeChief Subd OPS
G:\EXPLOITA\Doc_Ops\LOA Electronic 3 years 5 years
Safety occurrences
analysisConfide
ntial
Chief SubdSafety
Office Chief Subd Safety Paper 3 years 5 years
SMS requirements
TO PROMOTE SAFETYMEANS TO BUILD A SAFETY IMPROVEMENT CULTURE WITHIN THE
ORGANISATION
LESSON DISSEMINATIONDISSEMINATING PAST LESSONS WITHIN THE ORGANISATION
SAFETY IMPROVEMENTINVOLVING ALL STAFF AND IMPLEMENTING THE IMPROVEMENT OF SAFETY AS A CONTINUOUS PROCESS
SMS requirements
TO PROMOTE SAFETYMEANS TO BUILD A SAFETY IMPROVEMENT CULTURE WITHIN THE
ORGANISATION
LESSON DISSEMINATIONDISSEMINATING PAST LESSONS WITHIN THE ORGANISATION
SAFETY IMPROVEMENTINVOLVING ALL STAFF AND IMPLEMENTING THE IMPROVEMENT OF SAFETY AS A CONTINUOUS PROCESS
LESSON DISSEMINATIONDISSEMINATING PAST LESSONS WITHIN THE ORGANISATION
Lesson dissemination is included in module 4.
MODULE 4Safety Occurrences
SMS requirements
TO PROMOTE SAFETYMEANS TO BUILD A SAFETY IMPROVEMENT CULTURE WITHIN THE
ORGANISATION
LESSON DISSEMINATIONDISSEMINATING PAST LESSONS WITHIN THE ORGANISATION
SAFETY IMPROVEMENTINVOLVING ALL STAFF AND IMPLEMENTING THE IMPROVEMENT OF SAFETY AS A CONTINUOUS PROCESS
SAFETY IMPROVEMENTINVOLVING ALL STAFF AND IMPLEMENTING THE IMPROVEMENT OF SAFETY AS A CONTINUOUS PROCESS
Continuous improvement is a ISO 9001 quality concept but it applies also to safety.
Deming wheel : Plan, Do, Check, Act PDCA cycle.
SAFETY IMPROVEMENTINVOLVING ALL STAFF AND IMPLEMENTING THE IMPROVEMENT OF SAFETY AS A CONTINUOUS PROCESS
Provide ATS services
SAFETY OCCURRENCES- Analyse- Causes- GravityAUDITSREVIEWSCorrective
actions to avoid same causes
PolicyAction planObjectivesResources
SAFETY IMPROVEMENTINVOLVING ALL STAFF AND IMPLEMENTING THE IMPROVEMENT OF SAFETY AS A CONTINUOUS PROCESS
Continuous improvement is never completed.
You must climb slowly, step by step.
SAFETY IMPROVEMENTINVOLVING ALL STAFF AND IMPLEMENTING THE IMPROVEMENT OF SAFETY AS A CONTINUOUS PROCESS
2 Management review per year.
Implementation by
Members of the management review :- Chief of ACC or Airport (chairman of the revue) and deputy- RSMS (secretary of the revue)- Chief of operational division - Deputy of operational division - Chief of technical division- Deputy of technical division- Chief of administrative division
ManagementReview
Audit reports(internal, external)
Safety IndicatorsSafety Dashboard
List ofPlanned changes
Project of internal and external audits
PreparationAnalysis
Synthesisdone
byRSMS
List of corrective actions
Actions plan Minutes ofManagement
ReviewActions
ActionPlan
(update)
Planningof
audits
SAFETY IMPROVEMENTINVOLVING ALL STAFF AND IMPLEMENTING THE IMPROVEMENT OF SAFETY AS A CONTINUOUS PROCESS
Implementation byImplementation byImplementation by
NewCorrective
Actions
SAFETY IMPROVEMENTINVOLVING ALL STAFF AND IMPLEMENTING THE IMPROVEMENT OF SAFETY AS A CONTINUOUS PROCESS
Agenda :
1. Safety indicators2. Risk assessment and mitigation3. Implementation of SMS4. Audit reports5. Corrective and Preventive Actions
Implementation by
Titre
END
- French civil Aviation Organization.
Module 3ANSP NSA How to work together ?
- French ANSP Organization.
- French NSA Organisation.
- Audits NSA.
- French civil Aviation Organization.
Module 3ANSP NSA How to work together ?
- French ANSP Organization.
- French NSA Organisation.
- Audits NSA.
French Civil Aviation Organization
General Directoratefor Civil Aviation
Directoratefor Air Transport
(DTA)
Directoratefor Air Navigation
(ANSP)
Directoratefor Civil Aviation
Safety (NSA)
DTA elaborates regulations. Most of the requirements are coming from ICAO and EU.
ANSP applies the regulations and provides services (ATM, CNS, AIS ).
NSA monitors ANSP through audits.The certificate of provider is issued by NSA.
French Civil Aviation Organization
- French civil Aviation Organization.
Module 3ANSP NSA How to work together ?
- French ANSP Organization.
- French NSA Organisation.
- Audits NSA.
French ANSP Organization
Directoratefor Air Navigation (ANSP)
Planning and StrategySubdirectorate
Human ResourcesSubdirectorate
FinanceSubdirectorate
The management of Safety, Security and Quality Mission
The EnvironmentMission
Operations Directorate (ACC, Airports )
Technical and Innovation Directorate
Operations Directorate (ACC, Airports )
SESW
5 ACC
Operations Directorate(ACC, Airports )
WE
N
Lyon
Nice
MarseilleWest Indies
Guiana
IndianOcean
11 Airports
AIS CESNAC
CESNAC = Centralised Air
Navigation SystemsOperations Centre
BrestCDG & Orly Strasbourg
Toulouse
Bordeaux
Lille
OperationsDivision
ATCO
TechnicalDivisionATSEP
AdministrativeDivision
ACC or AirportChiefDeputy RSMS
ACC or Airport Organization
A dedicated function has been identified and created in each entity (ACC, Airports, AIS and CESNAC). This function called RSMS (french acronym it means responsible of the SMS) is directly linked to the chief of the entity.The RSMS must implement and monitor the local SMS.
OPS Division
SubdivisionStudies
SubdivisionTraining
SubdivisionSafety
Paris ACC :- 550 ATCOs- Among them 100 ATCOs are in training.
Aera East12 teams of 18 ATCO
Aera West12 teams of 18 ATCO
FMP FISAlert
SubdivisionATCO OPS
ACC or Airport Organization
ACC or Airport Organization
Technical Division
SubdivisionRadar
SubdivisionTelecoms
SubdivisionTraining
SubdivisionSafety
Paris ACC :- 80 ATSEPs- Among them about 8 ATSEPs are in training.
SubdivisionFlight Plan
SubdivisionEnergy
Operational maintenanceSupervision 3 ATSEP
Supervision1 technician
French ANSP Organization
Directoratefor Air Navigation (ANSP)
Planning and StrategySubdirectorate
Human ResourcesSubdirectorate
FinanceSubdirectorate
The management of Safety, Security and Quality Mission
The EnvironmentMission
Operations Directorate (ACC, Airports )
Technical and Innovation Directorate
The management of Safety, Security and Quality Mission
The management of Safety, Security and Quality Mission
Internal Audits and Certification Division
Insurance of the Regulatory
Compliance DivisionSafety Performance Insurance Division
Systems Safety Division
A dedicated organization has been identified and created at the national level. A team called MSQS (french acronym, it means team in charge of the Safety, Security, Quality) is directly linked the the Director of the french ANSP.
The Management Of safety Security and Quality Mission
SESW5 ACC
HeadquartersMSQS
WE
NBrestCDG & Orly Strasbourg
Lyon
Nice
MarseilleToulouse
Bordeaux
West indiesGuiana
IndianOcean
11 Airports
Lille
AIS CESNAC
CESNAC = Centralised Air
Navigation SystemsOperations Centre
RSMS
RSMSRSMS RSMS
RSMS
RSMS
RSMS
RSMS
RSMS
RSMS
RSMS RSMS
RSMS
RSMS
RSMS RSMS
RSMS
RSMS
A network of RSMS coordinated by MSQS
The RSMS are coordinated by MSQS in order to mutualize and to share.Monthly meetings are piloted by MSQS.
- French civil Aviation Organization.
Module 3ANSP NSA How to work together ?
- French ANSP Organization.
- French NSA Organisation.
- Audits NSA.
Resource Management
EuropeanCooperation
Flight Crew
Airworthinessand Air
Navigation
Airports and Air Navigation
French NSA Organization
Security
West
SouthWest
South
South East
North
NorthEast
AntillesFrench Guiana
Centre East
IndianOcean
Local DepartmentsHeadquarters
Licence, medical control, training.
Directoratefor Civil Aviation Safety
Certification and monitoring of airlines and aircratfs.
The oversightand monitoring operations of NSA are done with the support of local departments.
Certification and monitoring of ANSP and Airports.
Control the security measures.
EASA monitors all the NSA.
SESW
5 ACC
WENBrest
CDG & Orly Strasbourg
Lyon
Nice
MarseilleToulouse
Bordeaux
West IndiesGuiana
IndianOcean
11 Airports
Lille
AIS CESNAC
CESNAC = Centralised Air
Navigation SystemsOperations Centre
West
SouthWest
SouthSouth East
North NorthEast
West IndiesGuiana
Centre East
IndianOcean
Local NSA
French NSA Organization
NSA headquarters
Staff Aptitude for Air Navigation
Air Navigation Systemsand Equipment
- Audits of SMS.- Monitoring Non Conformities.- Monitoring Correctives Actions.- Monitoring of safety events, safety records, safety performance.- Certification of ANSP.
Pole : Airports and Air navigation
Certification of ANSP
Monitoring of changes (Risk assessment and mitigation).
Monitoring of competences of ATCO and ATSEP.
Airports and Air Navigation
National certification of airports.
Airports
- French civil Aviation Organization.
Module 3ANSP NSA How to work together ?
- French ANSP Organization.
- French NSA Organisation.
- Audits NSA.
Program of audits :- Program over 6 years, 6 to 10 audits per year.- Defining audit objectives and audit program by adaptation based on the results of year n-1.- Annual monitoring plan taking into account the maturity, the identified risks and regulatory requirements.- Pool of auditors from Headquarter and Local Departments.
Particuliarities of audits DSNA- Large referential. - Multi-site audits.- Monitoring non-conformities and observations of previousaudits.- Harmonization at national level.
Audits NSA
Audits NSA
Program of audits over 6 years, 6 to 10 audits per year.
Defining audit objectives and audit program by adaptation based on the results of year n-1.
Particuliarities of audits DSNA- Large referential. - Multi-site audits.- Monitoring non-conformities and observations of previous audits.- Harmonization at national level.
Annual monitoring plan taking into account the maturity, the identified risks and regulatory requirements.
SESW
3 years
HeadquartersWE
NBrest
CDG & Orly Strasbourg
Lyon
Nice
MarseilleToulouse
Bordeaux
West IndiesGuiana
IndianOcean
2 years
Lille
AIS CESNAC
Each year
Audits NSA : Periodicity
DSNA (french ANSP) : a national provider with more than50 sites.
DSNA provides ATS, CNS and AIS.
2006 DSNA obtained the certificate of Air Navigation Services Provider issued by the DSAC. The certificateended in 2010.2010 Renewal the certificate, valid until 2016.
Certificate of ANSP provided by NSA.
DSNA has an ISO9001 certification since 2009.
DSAC (French NSA) performs regular coordination with DSNA (twice a year).
Non Compliance
ACC X define Corrective Actions
MSQS checks with othersEntities
Corrective Actions accepted by MSQS?
Audits NSA : From Non Compliance to Corrective Actions
Corrective Actions accepted by NSA ?
Yes
MSQS proposes corrective actions to NSA
No
YesCorrective actions are implemented by ANSP and monitored by NSA
No
NSA considers that a non compliance found in an entity concerns the whole ANSP.
Audits NSA : From Non Compliance to Corrective Actions
MSQS must verify that the corrective actions can be applied by all the entities.
The corrective actions must be implemented in all the entities.
MSQS and NSA monitor the implementation of corrective actions and their effectiveness.
MSQS monitors all the corrective actions of the ANSP (linked to NSA audits).
Audits NSA : Monitoring Corrective Actions
MSQS and RSMS have a tool called AGATHA in which all the non compliances and the corrective actions are stored.
Twice a year MSQS has a meeting with NSA in order to monitor the corrective actions in progress.
Sometimes a corrective action needs several months to be completed.
The annual safety report of ACC X shows that all the safety events are not reported spontaneously by the ATCOs :- RA TCAS: 2 of 16 are reported. - Losses of separation 50: 1 on 3 is reported.- Losses of separation 70: 7 of 22 are reported.Non Compliance 1 : All the safety events are not reportedby the ATCOs.
Audits NSA : Exemple of Non Compliance
Explanation : When 2 aircrafts are under the minima of separation the event is automatically stored in a log file. So the ATCOs consider that it is not useful to report the safety events by filling a dedicated form (ATS Occurrence Report)..
Action 1. Note to the ATCOs to ask them to report all events they are aware (AIRPROX, RA TCAS, Losses of separation).
Audits NSA : Example of Corrective Actions
Every agent must report all the safety events which he is aware.
Action 2.A new indicator is implemented in order to monitor the ratio number of reported events by ATCOs / number of events.
Audits NSA : Example of Corrective Actions
The note to ATCO has been done in August 2008. An improvementhas been observedfrom September2008 and, of course, in 2009.
Action 3.Communication to ATCOs via briefings, safety commission, feedback
Audits NSA : Example of Corrective Actions
Between May 2008 and December 2009 during each briefing, each safety commission and each feedback, the mandatory notification of safety occurrences is reminded.
Module 4Safety Occurrences
Definitions, List of Safety Occurrences
Report and Notification
Analysis (Severity, Frequency, Causes)
Corrective Actions, Feedback
Safety occurrences
Regulations and Methodology of the French ANSP
Module 4Safety Occurrences
Definitions, List of Safety Occurrences
Report and Notification
Analysis (Severity, Frequency, Causes)
Corrective Actions, Feedback
Safety occurrences
Regulations and Methodology of the French ANSP
ICAO Annex 19
Requirements in Annexe 19
Guidance in DOC 9859
ICAO Annex 19
1. Safety Policy and Objectives
2. Safety Risk Management
3. Safety Assurance
4. Safety Promotion
Requirements for Safety Occurrences.
ICAO Annex 19
2. Safety Risk Management
2.1 Hazard identification.2.2 Safety risk assessment and mitigation
ICAO Annex 19
2. Safety Risk Management
2.1 Hazard identification.Notification, immediate actions, analysis of eventsProcessing of safety occurrencesProcessing of security occurrencesPlanning tools and resources2.2 Safety Risk Assessment and MitigationSafety studies (changes)Programmed method of interventionMonitoring measures to reduce risk
ICAO Annex 19
4. Safety Promotion
4.1 Training and education.4.2 Safety communication.
ICAO Annex 19
4. Safety Promotion
4.1 Training and education.SMI trainingCompetency (ATCO, ATSE)4.2 Safety communication.Lesson dissemination
Requirements
European requirements
Guidance : classificationfor severity and frequency
ESARR2 Summary
EAM2/GUI1 Summary
Attachment 1 is used for OPS events.
Attachment 2 is used for Technical events.
Regulations : ICAO Annex 19, DOC 9859,
ESARR2, EAM2/GUI1
Assessment of safety occurrences
Safety events : How to do analysis ? How to classify severity and frequency ? How to search causes ? The regulations are not enough explicit.
French ANSP Methodology
This methodology explains how to do the assessment of the safety occurrences : report, notification, analysis
Satety Occurrences : Methodology of the French ANSP
French ANSP Methodology
Procedure :Findings/
Corrective Actions
Manual :Assessment of
Safety Occurrences
Satety Occurrences : Methodology of the French ANSP
Manual for Assessment of safety occurrences
This manual is used by Safety Subdivisions (OPS andTechnical).
Module 4Safety Occurrences
Definitions, List of Safety Occurrences
Report and Notification
Analysis (Severity, Frequency, Causes)
Corrective Actions, Feedback
Safety occurrences
Regulations and Methodology of the French ANSP
Definition : ATM Safety Occurrences
Occurrences : Accidents, serious incidents and incidentsas well as other defects or malfunctioning of an aircraft, itsequipment and any element of the Air Navigation Systemwhich is used or intended to be used for the purpose or inconnection with the operation of an aircraft or with theprovision of an air traffic management service ornavigational aid to an aircraft.
List of Safety Occurrences(To be Reported and Analysed)
1. Accidents : Mid Air collision, Controlled Flight Into Terrain (CFIT), Collision on the ground between aircraft, Collision between an airborne aircraft and vehicle/another aircraft on the ground, Collision on the ground between aircraft and vehicle or person or obstruction(s), Other accidents of special interest would include losses of control in flight, due to VORTEX or meteorological conditions.
2. Incidents :Near collision Separation minima infringement, Inadequate separation, Near Controlled Flight Into Terrain (Near CFIT), Runway incursion where avoiding action was necessary.Potential for collision or near Runway incursion where no avoiding action is necessary, Runway excursion by aircraft, Aircraft deviation from ATC clearance, Aircraft deviation from applicable ATM regulation:
List of Safety Occurrences(To be Reported and Analysed)
5 NM
5 NM
5 NM
Horizontal separation (aircrafts same flight level FL)
En route minimum horizontal separation 5 NM.
1 000 FT
Vertical separation
FL 220
FL 210
En route minimum vertical separation 1 000 FT.
Short Term Conflict Alert STCA
The Short Term Conflict Alert (STCA) informs the ATCO when 2 aircrafts are going under the minima of separation.
Visual alarm : aircrafts involved are in red on the radar screen
3. ATM-specific occurrences (technical)This shall include the following occurrences: Inability to provide Air Traffic Management Services: Failure of Communication function, Failure of Surveillance function, Failure of Data Processing and Distribution function, Failure of Navigation function, ATM system security.
List of Safety Occurrences(To be Reported and Analysed)
Module 4Safety Occurrences
Definitions, List of Safety Occurrences
Report and Notification
Analysis (Severity, Frequency, Causes)
Corrective Actions, Feedback
Safety occurrences
Regulations and Methodology of the French ANSP
Safety Occurrences
Safety Event
CausesBad radio communications, Human error
Incursion of a vehicle on the runway
ConsequencesInterrupted landing, collision
What did he say ? We could
go I believe
Vehi grrr unway
Runway incursions : Danger
Be careful. Be sure that the radio communications are understood
by your correspondent
Safety Event
Causes
Consequences
To find the causes, we have to investigate the safety event.
A safety event must be reported.
Unfortunately the only thing we can do is to try to minimize the consequences.
Safety Occurrences
Safety Event
Causes
Consequences
To avoid the occurrence of a safety event we have to delete the causes.
X If we delete the causes
we also delete the consequences.X
Safety Occurrences
PolicyAction planObjectivesResources
Safety Occurrences Assessment - Analyze- Severity- Causes Corrective
actions to avoid same causes
Provide ATM & CNS servicesInstall and maintain ATM & CNS
Safety occurrences : Losses of separation,Technical events
Safety Occurrences
Improvement loop for safety occurrences.
Module 4Safety Occurrences
Definitions, List of Safety Occurrences
Report and Notification
Analysis (Severity, Frequency, Causes)
Corrective Actions, Feedback
Safety occurrences
Regulations and Methodology of the French ANSP
Safety Occurrences : Report and Notification
Record eventin database
List of eventsto be notifiedto managers
Real Time
SafetyOccurrence
Immediate Actionsif necessary
ECCAIRS : European Coordination Centre for Accident and Incident Reporting Systems.Toward next step
(analysis)
ECCAIRS Database
Report
ATCOs, ATSEPs, Pilots
How to Report safety occurrences to safety subdivisions ?
The reports of the safety occurrences are done by using a dedicated form.
Different forms are available :- Form for ATCO (AIRPROX, Losses of separation ).- Form for ATSEP (technical events, failure of systems ).
All the infringements of the norm (for French ANSP : less than 5 NM horizontal, less than 1000 ft) are automatically recorded in a log file.
Safety Occurrences : Report and Notification
ATCO Occurrence Form 1/2
X
XTP FL280 28/10/2014 12:15 X
AFR F-ABCD A320 LFPG LFML X1457 IFR
XBAW G-KLMN B737 EGLL LIRF IFR2812
RATCAS
123,45 YES NO
A AWY Radar control
XX X
X6002,4
Explanation of the incident by ATCO involved.
X
X
ATCO Paris/ACC 01:05 04:05
None
ATCO Occurrence Form 2/2
ATSEP Occurrence Form 1/2
X
X
Position TT 611/02/2014 S03X
11/02/2014
X
ATSEP Occurrence Form 2/2
The backup computer that manages the radar screen was out of service without any alarm. The backup computer seems to be frozen since several hours and displays an image of the radar situation at 9h22 pm.After a reset situation OK.
XSupervisor
List of events to notify immediately
Accident
Near collision (situations where one aircraft andanother aircraft/the ground/a vehicle/person or object is perceived to be too close to each other) :
- Landing or attempted landing on an occupied or closed runway.
- Takeoff or attempted takeoff on an occupied or closed runway.
Event emergency reported by the pilot to the ATCO.
- Losses of separation (50%) and RATCAS.
Failure of Communication function.
List of events to notify immediately
Inability to provide ATM or CNS Services.
Failure of Data Processing and Distribution function.
Failure of Surveillance function.
ATCO or ATSEP
OperationalDuty
Engineer
ACC or Airport
Analyzewith experts
Chief Chief OPSChief Tech
RSMS
Y
N
END of notification process
Notification Process (mail, phone ).
Chief ANSP MSQS NAS
BEAOffice
investigation analysis
Y
Eventmust be notify ?
Outside ACC or Airport
Notification Process
Who is the operational duty engineer ?
Each week the operational duty engineer is chosen among the chiefs of subdivisions and their deputies.
Module 4Safety Occurrences
Definitions, List of Safety Occurrences
Report and Notification
Analysis (Severity, Frequency, Causes)
Corrective Actions, Feedback
Safety occurrences
Regulations and Methodology of the French ANSP
Analysis
ECCAIRS : European Coordination Centre for Accident and Incident Reporting Systems.
Toward next step(search causes)
SearchCauses ?
The databasesare updated during analysis
Safety Subdivision or safety commission
To determine if causesmust be searcheda matrix is used by thesafety Subdivision
N
END
Safety Subdivision
Severity and FrequencyClassification
Debriefing of ATCOor ATSEP involved by
safety subdivision
Y
Analysis
Causes evaluatedby safety
commission
ECCAIRS : European Coordination Centre for Accident and Incident Reporting Systems.
Toward next step(corrective actions)
The databasesare updated during analysis
Y NSafetyCommission
?
Causes evaluatedby safety
subdivision
OPS Division : Severity
Two levels of severity:- Global severity (ATC + aircraft)- ATC Severity.
The ATC severity is the most interesting for us, because we can work to improve it.
If we have a problem with a flight we must inform the airline. If we have too many problems with the same airline we must inform our National Supervisory Authority.
Classification SignificationA : Serious incident ICAO Annex 13: An incident involving circumstances
indicating that an accident nearly occurred.Note: The difference between an accident and a serious incident lies only in the result.
B : Major incident An incident associated with the operation of an aircraft, in which safety of aircraft may have been compromised, having led to a near collision between aircraft, with ground or obstacles (i.e., safety margins not respected which is not the result of an ATC instruction).
C : Significant incident An incident involving circumstances indicating that an accident, a serious or major incident could have occurred, if the risk had not been managed within safety margins, or if another aircraft had been in the vicinity.
D : Not determined An incident which has no safety significance.E : No safety effect Insufficient information was available to determine the risk
involved or inconclusive or conflicting evidence precluded such determination.
OPS Division : Severity
Classification ExamplesA : Serious incident - Critical near collision between aircraft or between aircraft and
obstacle(s).- Separations lower than half the separation minima.- Controlled Flight Into Terrain only marginally avoided- Aborted take-offs/landings on a closed or engaged runway- Take-offs/landings from a closed or engaged runway
B : Major incident - Loss of separation (separation higher that half the separation minima) which is not fully under ATC control.- Safety margins not respected ( higher than half the applicable safety margins) which is not fully under ATC control.
C : Significant incident - After visual contact between two aircraft, no avoidance manoeuvre was seen as necessary or was carried out within safety margins.- Aircraft deviation from ATC clearance (such as flight level, route, heading, runway)- Unauthorised penetration of airspace.- Runway incursion with no other traffic in the vicinity (hence, where no avoiding action was necessary).
OPS Division : Severity
OPS Division : Severity
EUROCONTROL provides some guidelines to classify severity by using Reason plates. For each plate you have to answer some questions and you get points given for each answer. The amount of points helps you to choose the severity.
Regulations
ManagementControllers
Equipments
Examle of question :The event has been :- detected on time (-1)- detected late. (0)- detected by somebody else.(2)- never detected. (3)- detected and forgotten. (2)
FREQUENCY DEFINITION5 Extremely rare Has never occurred yet throughout the total lifetime
of the system.4 Rare Only very few similar incidents on record when
considering a large traffic volume or no records on asmall traffic volume.
3 Occasional Several similar occurrences on record - Hasoccurred more than once at the same location.
2 Frequent A significant number of similar occurrences alreadyon record - Has occurred a significant number oftimes at the same location.
1 Very Frequent A very high number of similar occurrences alreadyon record- Has occurred a very high number of timesat the same location.
OPS Division : Frequency
5 levels of frequency has been defined.
Technical Division : Severity
For technical events we use the same severity than for the global ATM severity.
We use lower case letters !
OPS Division : Classification matrix for severity and frequency
Serious A1 A2 A3 A4 A5Major B1 B2 B3 B4 B5
Significant C1 C2 C3 C4 C5Not determined D1 D2 D3 D4 D5No safety effect E1 E2 E3 E4 E5
Veryfrequent
Frequent Occasional Rare Extremelyrare
A safety occurrence is characterized by two items : - Severity- Frequency
OPS Division : Classification matrix for severity and frequency
Serious A1 A2 A3 A4 A5Major B1 B2 B3 B4 B5
Significant C1 C2 C3 C4 C5Not determined D1 D2 D3 D4 D5No safety effect E1 E2 E3 E4 E5
Veryfrequent
Frequent Occasional Rare Extremelyrare
The causes must be searched for the safety occurrences in the red area (example).
OPS Division : Safety Commission
Composition of the commission: Head of OPS division. Head of Subdivisions Studies, Training, Safety.ATCO involved, others ATCO, experts ...Brainstorming to identify causes.
Replaying radar data
Replaying radio communications
Causes
The numbers are the references in the database.
A safety occurrence can have several causes (455, 443 ).
It is very important to define corrective actions on the main causes.
We have to identify the different categories of causes, specially for the human factors.
Horizontal and vertical distribution of safety eventsft
NM
NM
ft
Inside red rectangle we are 50% under the minimum of separation, inside the orange 70%, inside the yellow 80% and inside the blue 100%.
Comparison between year Y-1 and year Y of the horizontal and vertical distribution of losses of separation.
Year Y -1
Year Y
A very bad loss of separation with 1,4 NM (horizontal) and same level (vertical).
Geographic distribution of safety events by severity
This graph shows us that we have a lot of safety events in sector AO. So we decided to modify the structure of this area and to create another sector.Sometimes we are taking corrective actions when we have several safety events with the same cause.The causes are :- too much traffic,- a bad design of the airspace.In module 6 we will see the change we have done to create a new sector.
Load Sector Description ATMsev
ATCsev
Freq Ref A/C 1 A/C 2 Lossof Sep
66% RT2 aircrafts going to Orly. 2nd one goes faster than 1st.Bad reaction to STCA.
C b 3 497 AFR1301
AFR5573
100%
OPS division : Safety occurrence 1Analyze
5NM
Load Sector Description ATMsev
ATCsev
Freq Ref A/C 1 A/C 2 Lossof Sep
107%
AOClearance given tooearly.No reaction to STCA.No use of emergency phraseology.
C b 4 668 TAR964 AF415N
100%
OPS division : Safety occurrence 2Analyze
D
Load Sector Description ATMsev
ATCsev
Freq Ref A/C 1 A/C 2 Lossof Sep
83% UP Level Bust. B e 3 603 AF814WL
VPBBV
70%Pilote
OPS division : Safety occurrence 4Analyze
1 000 FT
FL 220
FL 210
FL 200
1 000 FT
Level bust this aircraft does not stop at FL200 (clearance).
Technical Division : Severity
For technical events, we use the same severity grid than for the global ATM severity.
But we use lower case letters !
Technical Division : SeveritySEVERITY DEFINITION
aa Total inability to provide safe ATM service
An occurrence associated with the total inability toprovide any degree of ATM Services in compliance withapplicable Safety Regulatory Requirements, where:There is a sudden and non managed total loss ofATM service or situation awarenessThere is a totally corrupted ATM service or corruptedinformation provided to ATS personnel.
a Serious inabilityto provide safe ATM service
An occurrence associated with almost a total and suddeninability to provide any degree of ATM Services incompliance with applicable Safety RegulatoryRequirements. It involves circumstances indicating thatthe ability to provide ATM services is severelycompromised and has the potential to impact manyaircraft safe operations over a significant period of time.
b Partial inability to provide safe ATM service
An occurrence associated with the sudden and partialinability to provide ATM Services in compliance withapplicable Safety Regulatory Requirements.
Technical Division : Severity
SEVERITY DEFINITIONc Ability to provide safe butdegraded ATM service
An occurrence involving circumstances indicating that atotal, serious