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
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