Normal Operations Safety Survey

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NOSS
Normal Operations Safety Survey Airservices
Australia Marcus Knauer
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Why are we here?

• Member of ICAO NOSS Study Group.
• Undertook First Operational NOSS Trial April
  May 2005.
• Share our experience.

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Current Data Sources?

• Electronically Submitted Incident Reports.
• Incidents.
• Events
• Technical Fault Reporting.
• Audits
• Regulator/Internal - compliance
• Check and Training reports.

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NOSS Trial

• Focus
• Trial implementation was used to determine
  whether such a concept was appropriate within an
  ATS environment.
• Whether the methodology developed to date by the
  ICAO Normal Operations Safety Survey Study Group
  (NOSSSG) was suitable.
• Valid Snapshot of Brisbane Centre Operations

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What we did.

• Controller Association briefing.
• Joint Management/Union sponsorship.
• All controllers received TEM briefing.
• Publicised project and its intent.
• Created a NOSS web page.
• Observers selected were jointly nominated by
  management and union.

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The Trial

• 5 Observers, 5 Groups (Radar Enroute and
  Arrivals)
• 1 week Observer Training
• Theory, 2 trial observations, calibration
  session.
• 2 weeks Data Collection
• 52 observations
• 292 threats
• 139 errors
• 33 undesired states
• 1 Week Data Cleaning
• UT, Project Manager, Observer, Procedures
  specialist.

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What we saw

• Validated incident reports and incident
  investigation findings.
• Causal factors in recent incidents the same
  Controller behaviour was exhibited during NOSS.
• One of the groups contributed a significant
  proportion of Undesired States.

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What we saw

• 40 of threats were ANSP (organisational)
• STAR Clearances, other controllers, unserviceable
  equipment.
• 60 of threats were Airborne/Environmental
• Most Prevalent Restricted Airspace, Airspace
  Design, pilots.
• Most mismanaged threat - other controllers
• Errors recorded on 77 of observations
• 33 equipment/automation, 33 procedural, 25
  communication.
• 33 Undesired States
• Majority pertaining to inaccurate traffic
  representation.

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What we saw

• Controller Briefings poor prior to commencement
  of shift.
• Handover Takeovers poor, incomplete, not all
  pertinent operational information conveyed.
  Checklists not being adhered to.
• Controller Air Situation Display not kept up to
  date. Too much Human Machine Interface
  interaction?
• Full readbacks not being obtained from pilots and
  ATC.
• Inconsistent application of procedures across
  similar groups.

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Lessons Learned.

• Joint Management/Union sponsorship significant
  time frame.
• Scheduling of observations with training ad hoc
• Observer Selection.
• Observer overload.
• Supervision.
• Controller refusals testing the waters

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Whats Happened to date?

• Tangible
• Introduction of new HO/TO checklist on one Group.
• Intangible
• Observers adopting practices witnessed during
  observations, taking them back to their group.
• Increasing skill sets.

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Where to next?

• Brief Board Safety and Environment Committee in
  December.
• Initiate Safety Change.
• Trial in Tower Units.
• Incorporate into Business Operations.
• Collaborate with airlines.
• Develop Threat and Error Management training
  program for controllers.

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NOSS
Watch this space!