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NOSS – the trial(s) in Europe

Alexander Skoniezki, Head of Safety, Security and Human Factors Division on behalf of

Manfred Barbarino, Human Factors Domain Manager (DAP/SSH)- EUROCONTROL -

manfred.barbarino@eurocontrol.int

European Organisation for the Safety of Air Navigation

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Trial Objectives

2006/2007

2-3 Trials in

European

ANS Providers

NOSS - does it work in Europe ?

Lessons learned

Areas of Improvement

Input NOSS Study Group

Input ICAO NOSS manual

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NOSS Context – Managing ATM Threats & Errors

Analysis& Learning

ATMThreats &

Errors

Prevention

Mitigation& Coping

Team Resource Management

Error Analysis e.g. HERA/JANUS

Critical IncidentStress Management

ICAONormal Operations

Safety Survey

HF in Safety Management

Systems

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First European Trial – FINAVIA in 2006

ATC SitesANS Centre – Tampere

Airport – Helsinki

6 Observers4 ACC + 2 TWR/APP

Each 9 -12 Observations

63 ObservationsTotal = 54 h 25 min

10 NOSS Operating Characteristics applied

EUROCONTROLData Collection Site

EUROCONTROLProject Manager +Training Facilitator

NOSS Trial

ACC 41 x Approach 9 x Tower 13 x

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FINAVIA NOSS Trial - Timeline

Presentation

FINAVIAManagement

Action Plan

Sites‘ Visit

BriefingsWorkforce &

Unions

PR – Material

Local co-ordinator

Observers‘Training

Real TimeSupport

Observationswithin

2 weeks

Data Verification

Phase

Data Analysis

+Report Writing

Final Report

+FeedbackSession

March2006

May2006

August2006

September2006

October2006

December2006

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Observation Results - Overall

63Observations

511Threats

176Errors

26Undesired

States

41ACC

13TWR

9APP

Limited SamplesResults to be treated with some caution !

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Observation Results - Statistics

63Observations

54 hrs 25 minM = 65 min each

511Threats (T)

M = 8.1 T per observation

176Errors (E)

M = 2.8 E per observation

26Undesired States (US)

M = 0.7 US per observation

475 (93%) - managed46 (7%) - ‘mismanaged’

168 (95%) - managed 8 (5%) - ‘mismanaged’

25 (96%) - managed 1 (4%) - ‘mismanaged’

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Observation Results – Event Coding Taxonomy

Level III

Threat CodeAirspace Penetration

Level I

Threat CategoryAirborne Threat

Level II

Threat TypeA/C Pilot Issue

Threats

Level II

Error CodeIncorrect Readback

Level I

Error TypeCommunication E.

Errors

Level I

U. State CodeIncomplete HO/TO

UndesiredStates

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Observation Results – Threat Types

0% 5% 10% 15% 20% 25% 30%

Equipment Threats (1100)

Workspace/Materials Threats(1200)

Other controller / Flight Data (1300)

Operational Performance Threats(1400)

Airport Layout (1500)

Airspace Infrastructure/Design(1600)

External or Foreign ServiceProviders (1700)

Ground Traffic (1750)

Aircraft Pilot Issue (1800)

R / T Communication (1900)

Traffic (2000)

Weather Threats (2100)

Tower

Approach

ACC

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• The NOSS observers coded 511 Threats

• 93% of observed Threats managed

• Most frequent Threats:- ACC setting - Threats internally generated by the organisation

- Tower setting - Threats generated by airborne side activity

• Threats caused by other controllers most frequent

• Twenty Threats related to position relief or opening/closing of a position

• Most of these were associated with the Threat Type ’Other controller’

Observation Results – Summary Threats

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Observation Results – Error Types

0% 10% 20% 30% 40% 50% 60%

Errors in Communication (4100)

Equipment / Automation Errors (4200)

Errors in the use of manipulation offlight strips or radar labels (4300)

Error in the execution ofprocedures Procedural Errors

(4400)

Aircraft Instruction Errors (4500)

Tower

Approach

ACC

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Observation Results – Summary Errors

• The NOSS observers coded 176 Errors

• 95% of observed Errors managed

• Most frequent Errors:- Related to communication

- Related to procedures

• Procedure Errors most likely to lead to further errors or undesired states

• Sixteen Errors linked to position relief or opening/closing of position

• Errors in communication appear to be the biggest challenge at handover

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Observation Results – Undesired States

Undesired State ACC Approach Tower

Inaccurate representation of traffic (1) 1 0 0

Unable to effectively monitor traffic on ground (8) 0 1 1

Incomplete HO / TO (2) 1 0 0

Traffic situation not being monitored (3) 1 0 0

Equipment failure (5) 1 0 0

Lack of separation assurance (50) 2 2 1

Deviation from route clearance (51) 4 0 0

RWY/TWY not verified to be clear for progress (53) 0 1 1

Airspace penetration (54) 2 0 0

Restricted airspace not protected (55) 1 0 0

Frequency congestion (56) 0 0 1

Aircraft is lined up on wrong runway/ wrong position (57) 0 0 2

Traffic congestion due to blocked taxi (58) 0 0 3

Total 26 13 4 9

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Observation Results – Undesired States

• The NOSS observers coded 26 Undesired States

• 96% of Undesired States managed

• One Undesired State was mismanaged

• High proportion of Undesired States were accounted for by Tower

- Traffic congestion leading to blocked taxi-way

• Eleven Undesired States seem to relate to airborne separation

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Examples – Good Practices (Helsinki)

“There are two runway crossings (via ZD and Y) and one intersection

departure (ZG) at the same time. As ZG departing ATR is starting its take-

off, second aircraft is cleared to cross runway. Controller did not specify this

time the crossing intersection, which could alarm pilots in ATR as they are

just departing. Generally controllers would be expected to specify

intersection - this represents a good practice.”

“Updating the SMR display for departing flights by dragging identification

from list to targets needs focusing and distracts from other more essential

duties. Good practice to be able to do this if one has the time.”

“The handover is dealt very well, all the affecting things are mentioned and

the previous controller stays a while afterwards and asks then whether it’s

ok for him to leave.”

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Lessons Learned: Strengths

Organisation‘s buy-in - communication & marketing essential+

Workforce – accepted the NOSS approach easily+

Observers - found process easy to understand and to use +

Observers - able to capture safety related performance+

Results - likely to provide useful data for safety improvements+

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Lessons Learned: Issues

Few observations for Tower and Approach-

Observation Narratives: English was not first language-

Codes for Threat, Error, Undesired States: Need major adaptation-

Capturing good practices within NOSS is very limited -

Reliability of observations and validity of data -

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FINAVIA Follow-up

Next steps

Analysis of NOSS report and narratives

Safety recommendations and actions

Monitoring execution of safety actions

Redoing NOSS in 2009/2010 ???

Trend Analysis NOSS 1 vs. NOSS 2

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NOSS – R&D Topics

Proposed

NOSS

R&D Topics

Reliability & validity of NOSS observations

„NOSS+“ (e.g. post observation interviews)

NOSS coding - customisation + benchmarking

Cost-benefit studies

Cultural and language differences

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NOSS in Europe – Way Forward

NOSS in Europe

Possible

Next Steps

2 additional NOSS trials in 2007/2008

NOSS promotional material

NOSS workshop

NOSS facilitator training

NOSS user group