NOSS the trials in Europe

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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_at_eu
  rocontrol.int

European Organisation for the Safety of Air
Navigation
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Trial Objectives
NOSS - does it work in Europe ?
Lessons learned
2006/2007 2-3 Trials in European ANS Providers
Areas of Improvement
Input NOSS Study Group
Input ICAO NOSS manual
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NOSS Context Managing ATM Threats Errors
Team Resource Management
Prevention
ICAO Normal Operations Safety Survey
HF in Safety Management Systems
Analysis Learning
Mitigation Coping
Error Analysis e.g. HERA/JANUS
Critical Incident Stress Management
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First European Trial FINAVIA in 2006
ATC Sites ANS Centre Tampere Airport Helsinki
6 Observers 4 ACC 2 TWR/APP Each 9 -12
Observations
10 NOSS Operating Characteristics applied
NOSS Trial
63 Observations Total 54 h 25 min
EUROCONTROL Data Collection Site
ACC 41 x Approach 9 x
Tower 13 x
EUROCONTROL Project Manager Training Facilitator
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FINAVIA NOSS Trial - Timeline
September 2006
October 2006
December 2006
March 2006
May 2006
August 2006
Final Report Feedback Session
Sites Visit Briefings Workforce Unions PR
Material Local co-ordinator
Observers Training Real Time Support Observatio
ns within 2 weeks
Data Verification Phase
Data Analysis Report Writing
Presentation FINAVIA Management Action Plan
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Observation Results - Overall
Limited Samples Results to be treated with some
caution !
63 Observations
41 ACC
13 TWR
9 APP
26 Undesired States
511 Threats
176 Errors
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Observation Results - Statistics
63 Observations 54 hrs 25 min M 65 min each
511 Threats (T) M 8.1 T per observation
176 Errors (E) M 2.8 E per observation
26 Undesired States (US) M 0.7 US per
observation
475 (93) - managed 46 (7) - mismanaged
168 (95) - managed 8 (5) - mismanaged
25 (96) - managed 1 (4) - mismanaged
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Observation Results Event Coding Taxonomy
Threats
Errors
Undesired States
Level III Threat Code Airspace Penetration
Level II Error Code Incorrect Readback
Level I U. State Code Incomplete HO/TO
Level II Threat Type A/C Pilot Issue
Level I Error Type Communication E.
Level I Threat Category Airborne Threat
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Observation Results Threat Types
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Observation Results Summary Threats

• 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

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Observation Results Error Types
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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
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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 its ok for him to leave.

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Lessons Learned Strengths
Organisations 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
Analysis of NOSS report and narratives
Safety recommendations and actions
Next steps
Monitoring execution of safety actions
Redoing NOSS in 2009/2010 ???
Trend Analysis NOSS 1 vs. NOSS 2
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NOSS RD Topics
Reliability validity of NOSS observations
Proposed NOSS RD Topics
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
2 additional NOSS trials in 2007/2008
NOSS promotional material
NOSS in Europe Possible Next Steps
NOSS workshop
NOSS facilitator training
NOSS user group