NOSS Trial May June 2005 Experience

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NOSS Trial May / June 2005Experience
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Format

• Brief History of Airways NZ
• Safety Culture
• Why we ran the trial
• Preparation for the Trial
• Conduct of the trial
• Management viewpoint
• Observers viewpoint
• Staff viewpoint (as told by an observer)
• Presentation of the Report
• Main findings
• Action Plan to address issues
• Summary of NOSS for Airways
• Questions

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CEO Perspective video
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Airways Loss of Separation Incidents per 100,000
Movements
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Main Trunk Managers perspective video
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Advantages of NOSS for Airways

• The use of TEM framework gave far greater
  structure than our Position Checks
• NOSS would allow a broader view of the
  organisation as a whole
• We saw potential to adopt TEM in other areas e.g.
  incident investigation
• The base concept was already well proven through
  LOSA which was being used by most of our major
  customers
• The analytical support offered by the UT was
  significant to a small organisation
• Clear guidelines, processes and forms were being
  developed by ICAO
• The potential to gain from the experience of
  other providers
• The potential for benchmarking

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Summary of Key Factors

• High level management support
• Union buy in
• Budget 30,000NZD
• Support from ICAO in the form of draft procedures
• Technical and analytical support from the UT

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Staff Communications

• Update on Airways involvement in the ICAO working
  group and general introduction to the NOSS and
  LOSA
• Discussion on TEM principles
• General update on the proposed trial, including a
  union endorsement
• Notice from senior management formally announcing
  the trail and highlighting their support and
  expectations
• Reminder that the trial is about to start

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Observer Qualities

• Professional Credibility
• Not just experience
• Not Checkers
• Some were quite junior
• Integrity
• Analytical
• Relatively open minded
• Many controller can be quite rigid in their
  thinking
• Enthusiasm and passion
• Wanted people who would promote and sell the
  process

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Video Tim 1
Tim Training Video
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Video Tim First Observation
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Departures
Arrivals
Planner
Slide Terminal Suite
Typical Terminal Radar Suite
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Co-Ord
SMC
Tower
Typical Tower Layout
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Tim Staff Perspective video
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Tim Data Cleaning
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Threat Prevalence 100 of observations had at
least one threat Total 363 threats observed
Threat Management 82 of 362 threats were
effectively managed 18 were mismanaged Total 65
threats mismanaged
Threats - Undesired State Linkage 7 of threats
were linked to undesired states 63 of 40
undesired states were linked to threats
Threat to Error Linkage 44 of 165 errors were
linked to mismanaged threat 56 of errors were not
Total 63 observations
Error Management 76 of 165 errors had
inconsequential outcomes 22 led to an undesired
state 2 led to additional error Total 40 errors
mismanaged
Error Prevalence 81 of observations had at
least one error 19 were error free Total 165
errors were observed
Detected Error Outcomes 74 of errors that were
detected were inconsequential 22 were linked to
undesired states 4 were linked to additional
error
Undesired State Prevalence and Management 45
of observations had US Total 40 USs 100 of 40
US were inconsequential
Error Response 13 of 165 errors were detected
by the observed controller 20 were detected by
another party 67 went undetected or were ignored
Undetected Error Outcomes 76 of errors that
were detected were inconsequential 22 were
linked to undesired states 2 were linked to
additional error
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Countermeasures

• 14 of the observations received a marginal
  rating for post-handover support.
• 11 received a marginal rating for workload
  management.
• Generally late opening of additional positions
• Not restricting traffic flow.
• Interestingly those controllers who received
  marginal ratings in this area also encountered
  more threats and had more mismanaged threats and
  errors than other controllers

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Recommendations

• 12 were made, 11 have been accepted for action
  e.g.
• Setting up working group with the airspace users
  to address Airborne / ground threats e.g. Similar
  callsigns, visual approaches etc
• Address co-ordination issues through TRM
• Mandate degraded mode training in annual cyclic
  training
• Review hand-off procedures in some sectors
• Adopt formal HO/TO procedures across all
  sectors(Checklists)
• Review opening and closing position procedures
  through cyclic training
• Review traffic complexity issues within specific
  sectors
• Increase training on ATS systems

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