Introduction

1. NOSS Marcus Knauer Airservices Australia First ICAO TEM & NOSS Symposium Luxembourg 9 & 10 November 2005

2. Introduction • Who we are • Preparation for the Trial • The Trial • Trial results • Action Taken • Lessons Learned

3. South East Asia & Indian Ocean Airspace Mumbai Manila FIR Oakland FIR Colombo Male Biak Jakarta Nauru Port Moresby Seychelles Bali Honiara Nadi (Fiji) Brisbane FIR Antananarvio Mauritius NZ Melbourne FIR Johannesburg Oceanic Auckland Oceanic

4. Air Traffic Statistics Nauru Honiara Brisbane FIR Melbourne FIR The Australian FIRs Approximately 11% of the world’s airspace • ATC Sectors (incl. terminal) • Brisbane = 40 (6 oceanic) • Melbourne = 51 (2 oceanic) • Flights Processed (typically) • Brisbane FIR = 2700/day • Melbourne FIR = 2900/day • Sydney Airport Traffic • 800/day • Brisbane Airport Traffic • 600 - 700/day

5. Hawaii (3 Control Towers) Guam & Saipan (2 Control Towers) Nauru High Level Airspace (under Contract) Approx 5000NM Airspace controlled by Airservices Australia Equator Honiara High level Airspace (under Contract) Australian Airspace

6. Comparisons – Australian Airspace / Europe

7. Why are we here? • Member of ICAO NOSS Study Group. • Undertook First Operational NOSS Trial April – May 2005. • Share our experience.

8. Current Data Sources • Electronically Submitted Incident Reports • Incidents • Events • Compulsory and Voluntary reporting • Technical Fault Reporting • Audits • Regulator/Internal – compliance • Hazard/Risk Analysis Findings/recommendations are managed through System Action Improvement Report (SAIR). • Check and Training reports

9. What we did • Established NOSS Project Steering Committee. • Controller Association briefing. • Joint Management/Union sponsorship. • All controllers received TEM briefing. • Publicised project and its intent. • Journal Articles in local staff newsletter, Corporate Safety Magazine. • Information in controller daily briefing folder – Joint Management/Union letter. • Created a NOSS web page. • Observers selected were jointly nominated by management and union.

10. NOSS Project Manager Role • Elicit Association involvement and buy in. • Facilitate communication. • Management briefings: Set organisation expectations. • Conduit between Union and Management • Organise resources. • Promote project. • Roster observers. • Trouble shoot during project.

11. 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

12. The Trial • 5 Observers, 5 Groups (Brisbane Centre Radar Enroute and Arrivals) • 1 week Observer Training • Theory days (2), trial observations (2), calibration session (1 on 1). • 2 weeks Data Collection • 52 observations • 5.6 threats per observation • 2.7 errors per observation • 6 undesired states for every 10 observations • 1 Week Data Cleaning • UT, Project Manager, Observer, Procedures specialist. • Report Production – 1 month

14. Weather Radar Auxiliary Display Air Situation Display (ASD) Voice Switching and Control System (VSCS) TAAATS Controller Workstation

15. 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. • Errors recorded on 77% of observations • 33% equipment/automation, 33% procedural, 25% communication. • 33 Undesired States • Majority pertaining to inaccurate traffic representation.

16. 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.

17. What we saw • High prevalence of threats which were managed well. • 90% of threats and errors were managed. • 50% of all undesired states were precipitated by a threat. • The two most prevalent threats were restricted airspace/airspace design threats. These threats were well managed. • 20% of controllers observed had superior scan. • These controllers were more likely to detect and manage their own errors as well as errors committed by other controllers. • Distractions posed by other controllers managed well.

18. What we saw • Data collected reflected and expanded upon incident reports and incident investigation findings. • Causal factors in recent incidents the same controller behaviour was exhibited during NOSS. • Showed these weren’t “one offs” but were prevalent in every day operations. • Normal behaviours

19. What we did with the results • Results presented to management. • Report findings analysed. • ‘Quick Wins’ identified and addressed. • Summary of results published to staff. • Report published on project website. • In the process of developing a structured long term approach to address report targets for enhancement.

20. What’s Happened to date? Tangible • Introduction of new HO/TO checklist on one Group. • Proposal to change airspace structure. • Introduction of new procedure to reduce likelihood information display/coordination error. • Unserviceable equipment – facilities manager investigating why availability requirements are not being met. Intangible • Observers adopting practices witnessed during observations, taking them back to their group. • Increasing skill sets of individual observers.

21. Lessons Learned. • Joint Management/Union sponsorship. • significant time frame. • Scheduling of observations with training. • ad hoc training not published • Observer Selection. • Getting the right people is imperative. • Observer overload. • Originally targeted 1½ - 2 hours per observation educed to 1 – 1¼. • Supervision. • Should be briefed separately • Controller refusals • Over emphasis of voluntary participation. Testing the waters.

22. Where to next? • Complete Safety Change. • Develop Threat and Error Management training program for controllers/supervisors incorporated in recurrent training. • Trial in Tower Units. • Incorporate into Business Operations. • Develop Lead Indicator measures • Collaborate with airlines. • Sharing data

23. NOSS Watch this space!