Safety Management in French CAA

1
Safety Management in French CAA

• From 91 to 95 in France
• 95 EATCHIP safety policy
• From 96 a formal safety plan
• Where are we in 2000 ?

2
From 91 to 95 in France

• 91  CNSCA  was created independent entity
  aiming at proposing measures that may avoid
  reproduction of assessed Airprox, thus
  reinforcing ATM safety
• First output in 92 creation of local  Quality
  and safety  units to assess airprox and STCA
  related incidents

3
Local safety unit

• Local Safety Commission

- recommendations - annual report
To local management
LSC
Safety indicators
- airprox - TCAS RA - STCA, dlt 2,5 NM et h lt
500 or 1000) -voluntary report
H24
Feedback for controllers
4
National safety organization
Recommendations Annual report
- Ministry of Transport
- CNSCA
- recommendations - annual report
LSC
- airprox - TCAS RA - STCA, -voluntary report
H24
schéma local
5
Methods and tools
6
A taxonomy for causes

• System failure (Hardware and Software)
• Rules and airspace organization
• Human factors
• Human error
• Procedures violation
• lack of proficiency
• others
• Working methods and operational procedures

7
Nov 95 EATCHIP SAFETY POLICY

• Almost all principles of the Policy were applied
  in France
• In particular were considered as adequate
• The incident reporting procedure (loss of
  separation type, Airprox, STCA, TCAS)
• the incident analysis and associated lesson
  learning procedures including CNSCA
• However, there was some doubt whether DNA had
• an explicit, pro-active approach to Safety
  management

8
96-97 building up a safety action plan

• How do we perceive safety in France ?
• Is there a safety policy ? Who is aware of it ?
• How do we learn and what have we identified ?
• What are our technical means and human resources
  ?
• What should be achieved to comply with EATCHIP
  and have a more pro-active approach ?
• List of actions
• Is there a need to change the safety organization
  ?

WG with 25  experts , including Union
representatives
9
Risk perception in French ATC

• Safety level is excellent 0 ACCIDENT ?
  4,5 in air transport accidents
• The  real  problems in ATC delays, strikes
• BUT...
• What about incidents as safety indicators?
• What about controllers perception ?
• What about the multiple and frequent changes ?

It is difficult to manage safety in ultra-safe
systems (R.Amalberti)
10
Risk Management in French ATC
Optimistic
or pessimistic ?
11
What we have learnt through incident analysis
over the past decade

• Is safety all about avoiding en-route air
  collision ?
• Airprox rate quite steady, BUT recurrent causes
• How to pick accident precursors in the database ?
• New sources gt new causes
• BUT still unexplored areas

The main causes Human Factors!
12
New glasses new picture

• STCA lt 5 Nm

• STCA lt 2.5 Nm

13
Controllers are risk managers

• External risk
• safety margin
• Internal risk
• Confidence
• Metaknowledge
• Human factors can degrade risk perception
• being aware/ keeping track of one s own
  competence
• over-confidence on data displayed
• group pressure

14
What are the main threats in ATC ?

• Human factors ?
• Situational Awareness, workload, teamwork
• Attitudes towards rules and procedures
• Hand-off, hand-over, sector splitting, sectors
  manning
• Risk management over confidence
• Fatigue, stress, proficiency ?
• Frequent changes impact on controllers risk
  management
• On ground operation, airspace organization
• Runway incursion, IFR/VFR

15
DNA Safety Action plan

• Achieved in July 98

16
The chapters of DNA Safety Action plan

• Implement the Safety Management structure
• Better promote Air Navigation Safety Policy
• Better formalise Safety related procedures
• Improve the incident reporting and analysis
  mechanism
• Improve experience feedback mechanism
• Improve Safety training
• Give special attention to Safety nets
• Involve the staff representatives

17
Safety Management Organisation

• A full time Safety manager was nominated at DNA
  level
• No Safety department was created at headquarters
  level
• Within each unit, a Safety Manager should be
  nominated
• reports directly to the executive manager of the
  Organism
• informs when needed the DNA Safety Manager
• is responsible for the proper Safety Organisation
  within his Organism
• No formal allocation of Safety responsibilities

18
Better formalise Safety related procedures

• Establish local Safety plans
• Formalise Safety analysis
• Safety case for systems procedures
• Who validates, who signs ?
• Formal management of operator manuals
• Formalise experience feedback follow ups

19
Improve the incident reporting and analysis
mechanism

• In line with 94-56 directive
• Insist on all significant incidents (not only
  loss of separation)
• Non punitive environment (well known in ACC
  through STCA)
• Set up differentiated incident analysis
  procedures
• Building up a database with a new taxonomy
• Modify relations with BEA
• Work in co-operation with airlines

20
New taxonomy (INCA)

• 1- rules and procedures
• 2- hardware and software
• 3- environment
• 4- air-ground communications
• 5- ground-ground communications
• 6- teamwork
• 7- individual human factors
• 8- situational awareness
• 9- decision making

21
Improve feedback ?
Intrinsic component
Tools Safety nets
Organization Procedures
Recruiting Training

• Decision Management

Experience Feedback
Traffic Events Failures ...
Technical state
Workload
Real organization
Operational component
22
What do we need as a feedback process ?

• Define a safety policy a will to understand and
  a will to act
• More staff to tackle safety issues, more
  training, quicker answer
• Better cooperation from controllers through
• Education, trust towards safety staff, feedback
• Use safety nets to trigger events

Need to improve our safety culture
23
Improve training

• Safety Management courses at ENAC
• Include TRM
• Use tools like RITA
• Enhance the training on emergency handling

24
Involve staff representatives

• Some Safety matters examined in WG including
  staff representatives
• Operator manual
• QS manning
• Runway incursions
• Emergency handling
• Met information on radar screen
• Control units manning
• Positive feedback
• MSAW example

25
CAP 2001 Air Navigation Safety Folder

• Orientation document drafted in spring 99
• by a group of motivated staff (not only
  management)
• The DNA has defined key actions
• practical actions rather then philosophy
• in line with the DNA Safety action plan
• follow up managed by DGAC
• Adoption end 1999

26
The Chapters of the plan (1)

• Promote Safety policy within DNA units
• Insist on Safety tools for airports
• Enhance feedback
• Reinforce QS units
• Find ways to attract people
• Merging technical and operational ?
• Initial and continuous training

27
The Chapters of the plan (2)

• Health and Safety
• Formalise procedures
• Safety case
• Operating manuals
• Safety Capacity relation
• Especially in case of contingency
• Special attention to 2 recurrent factors
• See and avoid limitations
• manning of operational sectors

28
Where are we in 2000 ?

• From CENA studies (Safety and Human Factors
  approach)

29
Still some concerns

• STCA implementation in TMA
• Procedure definition how to use it ?
• Impact on risk visibility ?
• Resources needed for training
• TRM
• Emergency situations
• Upgrade training on new systems
• Safety issues in system design ?

How can management get more involved in safety
issues ?
30
Conclusion

• Good points
• Strategic plan safety folder
• Safety working group
• More learning (database)
• Progress in safety culture
• Questions
• Effect of safety structure on safety culture?
• Still unexplored areas
• What can be done with a growing set of events ?
• Still difficult to be pro-active
• Lack of human resources