Airservices Australia The NOSS Experience Marcus Knauer NOSS Project Manager

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Airservices AustraliaThe NOSS
ExperienceMarcus Knauer NOSS Project Manager
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Why are we here?

• Member of ICAO NOSS Study Group
• Undertook First Operational NOSS Trial April
  May 2005
• Incorporated into Business Operations May 2006

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Current Data Sources

• Electronically Submitted Incident Reports
• Incidents
• Events
• Technical Fault Reporting
• Audits
• Regulator/Internal compliance
• Check and Training assessments
• Operational Risk Assessments
• Hazard Identification and Risk Analysis

WHY NOSS?
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NOSS Implementation

• Scope
• Snapshot of Brisbane/Melbourne Operations and
  Brisbane, Sydney and Melbourne Towers
• Centres
• 18 Groups
• Upper Airspace, Transitional Enroute and Terminal
• Towers
• 3 Towers
• Aerodrome Control and Surface Movement Control

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Centres Towers Observed
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Comparisons Australia / USA
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What we did

• Project Steering Committee
• Controller Association briefing
• Joint Management/Union sponsorship
• All controllers received TEM briefing
• Publicised project and its intent
• Created a NOSS web page
• Internal News letters
• Expressions of Interest - Observers were jointly
  endorsed by management and union

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Project Scope

• 14 Observers 9 from centres, 5 from towers
• 1 week Observer Training
• Theoretical knowledge, 2 trial observations,
  debrief session
• 8 weeks Data Collection
• 201 observations in centres
• 128 observations in towers
• Approximately 360 hours
• 2 Weeks Data Verification
• UT, Project Manager, Observer, Union
  representative and Procedures specialist

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Centre Threat Error Summary

• ERRORS
• Most Prevalent
• Checklists
• Incomplete/Inaccurate information display
• Full readback not obtained
• Computer/Automation Input Error
• Most Consequential
• Incomplete/Inaccurate Information display
• Not passing operational information
• Coordination Errors

• THREATS
• Most Prevalent
• R/T Communications
• Airspace
• Other Controllers
• Equipment/Software
• Most Consequential
• Controller Distraction
• Pilot Readback Error
• Equipment/Software
• Coordination

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What we saw - Centres

• Procedural Variation across both Centres, all
  Groups and Towers
• Checklists not being adhered to
• Non operational conversation
• Controller display not reflecting actual control
  state

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What we saw - Centres

• Greater number of undesired states in one of the
  centres
• 70 of all undesired states (46 of observations)
• Overall
• Inaccurate representation of Traffic/Airspace
• Critical information not passed/coordinated
• Inaccurate HMI
• Lack of Separation Assurance
• Aircraft not in contact with ATC
• Aircraft not in possession of important
  information

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Tower Threat Error Summary

• ERRORS
• Most Prevalent
• Phraseology
• Readbacks
• Flight Progress Strips
• Most Consequential
• Incomplete Inaccurate information display
• Flight Progress Strip Manipulation

• THREATS
• Most Prevalent
• R/T Communications
• Other Controllers
• Equipment/Software
• Most Consequential
• Other Controller Error
• Equipment/Software
• Pilot readback Errors
• Pilot failure to respond to calls

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What we saw - Towers

• Checklists not being used
• Runway Crossing procedures inconsistent
• Runway Incursion Action Plan
• Flight Progress Strip Errors
• Unnecessary software messages distracting
  Aerodrome Controller
• Not monitoring takeoff/landing
• Full readbacks not being obtained

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What we saw - Towers

• Tower 1
• Converging Runway Operation (Traffic Information,
  Visual Separation aircraft not on frequency)
• Tower 2
• Poor phraseology leading to lack of Separation
  Assurance on taxiway, not using procedure
  blocking strip
• Tower 3
• Not having RWY occupied strip Undesired State in
  other two towers

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Overall

• Validated incident reports and incident
  investigation findings.
• Causal factors in recent incidents the same
  Controller behaviour was exhibited during NOSS
• Identified systemic issues as well as issues
  which were location specific in both towers and
  centres

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Lessons Learned

• Association engagement
• Scheduling of observations with training
• Observer Selection
• Observer overload
• Controller refusals testing the waters
• Briefings to staff
• Level of appropriate detail

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NOSS Value

• Provides Lead Indicators
• Identifying Incident Precursors
• Enable development of proactive interventions
  rather than being reactive
• Focus of resources
• Intangible Benefits
• Validated Gut feeling

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Whats Happened to date?

• Tangible
• Particular errors in Groups who participated in
  Trial last year, significantly reduced same type
  of error
• NOSS Action plan Developed
• Intangible
• Observers adopting practices witnessed during
  observations, taking them back to their group
  capturing good practice

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Where to next?

• Publish findings to staff with action plan
• Initiate Safety Change - Implementation of NOSS
  action plan
• Collaborate with airlines, other ANSPs
• Develop Threat and Error Management training
  program for controllers using NOSS data
• Check Supervisors

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Additional Uses of NOSS Data

• Integration into organisations Operational Risk
  Assessments
• Enhance Incident Investigation process
• Exchange of data/issues with airlines
• Opportunity to address industry issues

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Thank You

• Questions?

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Action Plan

• Based broadly on Targets for Enhancement
• Immediate Actions Additional
• Facility Specific Actions Raw Data
• Ongoing Strategies Analysis
• CHALLENGE - Managing the Safety Change
  Process