Airservices AustraliaAirservices Australia

The NOSS ExperienceThe NOSS Experience

Marcus Knauer – NOSS Project Manager

Airservices AustraliaAirservices Australia

The NOSS ExperienceThe NOSS Experience

Marcus Knauer – NOSS Project Manager

Why are we here?

• Member of ICAO NOSS Study Group

• Undertook First Operational NOSS Trial April – May 2005

• Incorporated into Business Operations May 2006

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?

NOSS Implementation

Scope

Snapshot of Brisbane/Melbourne Operations and Brisbane, Sydney and Melbourne Towers

Centres18 Groups

– Upper Airspace, Transitional Enroute and Terminal

Towers 3 Towers

– Aerodrome Control and Surface Movement Control

Centres & Towers Observed

Brisbane CentreBrisbane Tower

Melbourne CentreMelbourne Tower

Sydney Tower

Comparisons – Australia / USA

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

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

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

• Procedural Variation across both Centres, all Groups and Towers

• Checklists not being adhered to

• Non operational conversation

• Controller display not reflecting actual control state

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

What we saw - Centres

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

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

• 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

What we saw - Towers

• 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

Overall

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

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”

What’s 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

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

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

Questions?

ThankThank

YouYou

Action Plan

• Based broadly on Targets for Enhancement

Immediate Actions AdditionalFacility Specific Actions Raw

DataOngoing Strategies Analysis

CHALLENGE - Managing the Safety Change Process