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Threat and Error Management & Normal Operations Safety Survey: The Perspective of ICAO Captain Dan Maurino Captain Dan Maurino Flight Safety and Human.

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Presentation on theme: "Threat and Error Management & Normal Operations Safety Survey: The Perspective of ICAO Captain Dan Maurino Captain Dan Maurino Flight Safety and Human."— Presentation transcript:

1 Threat and Error Management & Normal Operations Safety Survey: The Perspective of ICAO Captain Dan Maurino Captain Dan Maurino Flight Safety and Human Factors – ICAO Second ICAO Global Symposium on TEM & NOSS in ATC Washington, DC 7 – 8 February 2007

2 Operational performance Operationaldeployment Systemdesign Baseline performance Operational drift Learning from Failure & Success

3 Capturing the Drift Reactive systems Reactive systems Accident investigation Accident investigation Incident investigation Incident investigation Predictive systems Predictive systems Electronic safety data acquisition systems Electronic safety data acquisition systems Direct observation safety data acquisition systems Direct observation safety data acquisition systems Proactive systems Proactive systems Mandatory reporting systems Mandatory reporting systems Voluntary self-reporting systems Voluntary self-reporting systems Confidential reporting systems Confidential reporting systems

4 Safety Data Systems and Levels of Intervention Baseline performance Practical drift Operational performance organization Predictive ProactiveReactiveHighly efficientVery efficient Efficient Safety management levels Reactive Desirable management level Insufficient ASR Surveys Audits ASRMOR Accident and incident reports H i g h M i d d l e L o w Hazards FDA Directobservationsystems

5 NOSS & TEM – Predictive Safety Management Hazards in operational contexts – Threats Hazards in operational contexts – Threats Potential risk (s) – Operational Errors Potential risk (s) – Operational Errors Result (s) of hazards and risk (s) – Undesired States Result (s) of hazards and risk (s) – Undesired States TEM = Framework – What we look for TEM = Framework – What we look for NOSS = Tool – How we collect what we look for NOSS = Tool – How we collect what we look for

6 A Day at the Office To achieve companys both safety and production goals, air traffic controllers daily must Threat Management ErrorManagement Undesired States Management 3 Manage deviations Manage operational complexity 1 Manage their own errors 2 NOSSIndexes

7 Threats Similarcallsigns Similar call signs Reduced separation minima minima Airspace restrictions Runway crossings System malfunctions Missed approaches Communication failure Runway inspections LAHSO Noise restrictions Weather SIRO Heavytraffic Heavy traffic Airspacereclassification Events or errors that occur beyond the influence of the ATCO, increase operational complexity, and which must be managed to maintain the margins of safety

8 Errors Equipment handling errors – incorrect interactions with the equipment Equipment handling errors – incorrect interactions with the equipment e.g. selecting an inappropriate radar source; making incorrect inputs to an automated system Procedural errors – deficiencies in execution Procedural errors – deficiencies in execution e.g. wrong separation minima applied; leaving the position before replacement is ready to take over Communication errors – deficiencies in the exchange of operational information Communication errors – deficiencies in the exchange of operational information e.g. missed calls; misinterpretation of a request Actions or inactions by the ATCO that lead to deviations from organizational or ATCO expectations

9 Undesired States Aircraft climbing to a wrong altitude Aircraft climbing to a wrong altitude Aircraft turning in the wrong direction Aircraft turning in the wrong direction Aircraft enters a wrong taxiway Aircraft enters a wrong taxiway Aircraft missing a crossing restriction Aircraft missing a crossing restriction … Operational conditions where an unintended traffic situation results in a reduction of safety margins Outcomes Reportable events Reportable events Incidents Incidents Accidents Accidents

10 TEM – A Scenario B737 & C550 (on non-standard route) on reciprocal tracks at FL 310, rate of closure in excess of 800 knots B737 & C550 (on non-standard route) on reciprocal tracks at FL 310, rate of closure in excess of 800 knots When separated by 22 NM, ATCO (working two combined sectors) instructed both crews to alter heading and flight level When separated by 22 NM, ATCO (working two combined sectors) instructed both crews to alter heading and flight level Horizontal radar separation standard of 5 NM was never infringed Horizontal radar separation standard of 5 NM was never infringed Short-term conflict alert (STCA) activated Short-term conflict alert (STCA) activated Vertical separation was established 25 seconds prior to the aircraft passing Vertical separation was established 25 seconds prior to the aircraft passing

11 TEM Analysis Threats C550 on non-standard route C550 on non-standard route Use of non-standard levels Use of non-standard levels ATCO managing two combined sectors ATCO managing two combined sectors Errors ATCOs timing in recognising a potential conflict ATCOs timing in recognising a potential conflict Undesired State From 09:56:55 till 09:59:55 the B737 & the C550 were From 09:56:55 till 09:59:55 the B737 & the C550 were on opposite tracks at FL310 without separation provision

12 Undesired State Management The controller was spending a significant period of coordination with another sector controller.At 09:59:55, he activated the individual quick look function for the flight plan tracks of both aircraft. He immediately commenced action to ensure a separation standard was maintained. He instructed the 737 to expedite descent to FL290 and instructed the Citation to turn right 30 degrees. At 10:00:15, he further instructed the 737 to turn right 20 degrees. He broadcast essential traffic information to the 737 about the position of the Citation. During that transmission, the STCA activated at 10:00:28. At 10:00:34, the controller told the pilot of the Citation to climb to FL320. At 10:00:57, a 2,000 ft vertical separation standard was established when the aircraft were approximately 9 NM apart. The controller was spending a significant period of coordination with another sector controller. At 09:59:55, he activated the individual quick look function for the flight plan tracks of both aircraft. He immediately commenced action to ensure a separation standard was maintained. He instructed the 737 to expedite descent to FL290 and instructed the Citation to turn right 30 degrees. At 10:00:15, he further instructed the 737 to turn right 20 degrees. He broadcast essential traffic information to the 737 about the position of the Citation. During that transmission, the STCA activated at 10:00:28. At 10:00:34, the controller told the pilot of the Citation to climb to FL320. At 10:00:57, a 2,000 ft vertical separation standard was established when the aircraft were approximately 9 NM apart.

13 TEM & NOSS – ATC SMS Tools EDA Voluntary Reporting Direct observations


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