Presentation is loading. Please wait.

Presentation is loading. Please wait.

Monitoring Normal Operations in ATC: The State of Affairs Captain Dan Maurino Captain Dan Maurino Flight Safety and Human Factors – ICAO First ICAO Global.

Similar presentations


Presentation on theme: "Monitoring Normal Operations in ATC: The State of Affairs Captain Dan Maurino Captain Dan Maurino Flight Safety and Human Factors – ICAO First ICAO Global."— Presentation transcript:

1 Monitoring Normal Operations in ATC: The State of Affairs Captain Dan Maurino Captain Dan Maurino Flight Safety and Human Factors – ICAO First ICAO Global Symposium on TEM & NOSS in ATC Luxembourg 9 – 10 November 2005

2 Lets face it, folks…Were not rocket scientists

3 The First Ultra-Safe Industrial System Ultra-safe system (mid 1990s onwards) Business management approach to safety (SMS) Business management approach to safety (SMS) Routine collection and analysis of operational data Routine collection and analysis of operational data 10 -3 10 -5 10 -7 Fragile system (1920s -1970s) Individual risk management & intensive training Individual risk management & intensive training Accident investigation Accident investigation Safe system (1970s – mid 1990s) Technology & regulations Technology & regulations Incident investigation Incident investigation

4 NOSS The Safety Data Picture Forensic systems – Failures Forensic systems – Failures Accident investigation Accident investigation Major incident investigation Major incident investigation Proactive systems – Monitoring normal operations Proactive systems – Monitoring normal operations Electronic data acquisition systems Electronic data acquisition systems Voluntary self-reporting systems Voluntary self-reporting systems Direct observation data acquisition systems Direct observation data acquisition systems Reactive systems – Anomalies Reactive systems – Anomalies Mandatory reporting systems Mandatory reporting systems Voluntary reporting systems Voluntary reporting systems

5 Systemdesign Baseline (ideal) performance Baselineperformance Operationalperformance Practical PracticalDrift Operationaldeployment When the Book Goes Out of the Window

6 Operational Errors The safety consequences of operational errors depend on the context where they take place

7 B A Capturing the drift: context, not people

8 TEM & NOSS: Establishing the Relationship The features in operational context – Threats The features in operational context – Threats How the context influences what people do – Errors How the context influences what people do – Errors The results of the interaction between features in operational context and of what people do – Undesired states The results of the interaction between features in operational context and of what people do – 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 The Ten Operating Characteristics The Ten Operating Characteristics Normal ATC operations Normal ATC operations Capture an ATC system real performance through the eyes of its ATCOs

9 Safety Management – ICAO & IATA Safety Management – ICAO & IATA Single event analysis Single event analysis Integrated Threat Analysis (ITA) – ICAO & IATA Integrated Threat Analysis (ITA) – ICAO & IATA Cabin Operations Safety Toolkit (Turbulence & inadvertent slide deployment) – IATA Cabin Operations Safety Toolkit (Turbulence & inadvertent slide deployment) – IATA Auditing – NOSS & LOSA Auditing – NOSS & LOSA Training – Flight & Cabin Crew/ATCO (ICAO, IATA, ATS providers and Airlines) Training – Flight & Cabin Crew/ATCO (ICAO, IATA, ATS providers and Airlines) Research and development (UT & Boeing) Research and development (UT & Boeing) TEM Framework – Expanding Role

10 Training Flight crew ATCO Cabin Crew An Expanding Role SafetyManagement R&DUTBoeing AuditingLOSANOSS Error Management Threat Management Undesired State Undesired StateManagement ICAO ICAO

11 State Letter AN 12/17- 05/93 Aligned Safety Management Provisions Annex 6 – Operation of Aircraft, Parts I and III Annex 6 – Operation of Aircraft, Parts I and III Annex 11 – Air Traffic Services Annex 11 – Air Traffic Services Annex 14 – Aerodromes Annex 14 – Aerodromes A safety management template A safety management template Safety programme – States Safety programme – States Safety management system – Operators/providers Safety management system – Operators/providers Acceptable level of safety Acceptable level of safety

12 State Letter AN 12/17-05/93 Aligned Safety Management Provisions Three basic safety management processes Three basic safety management processes Hazard identification Hazard identification Remedial action Remedial action Monitoring of effectiveness Monitoring of effectiveness Direct accountability on the part of senior management Direct accountability on the part of senior management ICAO Safety Management Manual (Doc 9859) ICAO Safety Management Manual (Doc 9859) Normal operations monitoring Normal operations monitoring TEM, LOSA & NOSS TEM, LOSA & NOSS www.icao.int/anb/safetymanagement

13 State Letter AN 12/1.1-05/62 Annex 1 – Personnel Licensing Knowledge requirements Knowledge requirements Human performance including principles of threat and error management Human performance including principles of threat and error management Operational procedures – Application of threat and error management principles to operational performance Operational procedures – Application of threat and error management principles to operational performance Skills requirements Skills requirements Recognize and manage threats and errors Recognize and manage threats and errors

14 State Letter AN 12/1.1-05/62 Annex 6 – Operation of aircraft Chapter 9. Aeroplane Flight Crew 9.3 – Flight crew member training programmes 9.3.1An operator shall establish and maintain a ground and flight training programme, approved by the State of the operator…The training programme shall also include…training in knowledge and skills related to human performance including threat and error management…The training programme shall be given on a recurrent basis…

15 TEM & TRM: A Relationship Defined …TEM is an overarching safety concept with multiple applications in aviation; while TRM is exclusively a training intervention. The basic concepts underlying TEM (threats, errors and undesired aircraft states) can be integrated – for example as an additional module – within existing TRM programmes. This is because TEM countermeasures build in part – although not exclusively – upon TRM skills. The combination of TEM concepts with TRM skills thus introduces the opportunity to present the utilization of TRM skills by flight crews anchored in the operational environment, from an operational perspective. It is emphasized that TEM training does not replace TRM training, but rather complements and enhances it.

16 TRMSkills Error Management Threat Management Undesired State Undesired StateManagement TEM & TRM: The Bridge

17 TEM & NOSS – ATC Safety Management Tools EDA Voluntary Reporting Direct observations

18


Download ppt "Monitoring Normal Operations in ATC: The State of Affairs Captain Dan Maurino Captain Dan Maurino Flight Safety and Human Factors – ICAO First ICAO Global."

Similar presentations


Ads by Google