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

2. Let’s face it, folks…We’re not rocket scientists

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

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

5. When the Book Goes Out of the Window
Baseline
performance
“Practical
Drift”
Baseline (ideal) performance
Operational
deployment
System
design
Operational
performance

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

7. A
Capturing the “drift”:
context, not people B

8. TEM & NOSS: Establishing the Relationship
TEM = Framework – What we look for
The features in operational context – Threats
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
Capture an ATC system real performance
through the eyes of its ATCOs
NOSS =Tool – How we collect what we look for
The Ten Operating Characteristics
Normal ATC operations

9. TEM Framework – Expanding Role
Safety Management – ICAO & IATA
Single event analysis
Integrated Threat Analysis (ITA) – ICAO & IATA
Cabin Operations Safety Toolkit (Turbulence & inadvertent slide deployment) – IATA
Auditing – NOSS & LOSA
Training – Flight & Cabin Crew/ATCO (ICAO, IATA, ATS providers and Airlines)
Research and development (UT & Boeing)
This is our introduction to the RED FLAG concept. It is important to build recognition here. Many more Red Flags will be shown in the discussion of AA1420.
Also important to note here that, as the slide states, “a threat does not equal an error”. It only allows for the potential to commit an error. However, a threat should be perceived as a Red Flag to the crew, and even talked about amongst themselves as such.
Take one of the threats previously listed by the group and use as an example of how the threat could have become an error or not an error.

10. An Expanding Role Auditing Safety Management Threat Management ICAO
LOSA
NOSS
Safety
Management
Error Management
Threat Management
Undesired State
Management
ICAO
R&D UT
Boeing
Training
Flight crew
ATCO
Cabin Crew
ICAO

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

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

13. State Letter AN 12/1.1-05/62 Annex 1 – Personnel Licensing
Knowledge requirements
Human performance including principles of threat and error management
Operational procedures – Application of threat and error management principles to operational performance
Skills requirements
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
9.3.1 An 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. TEM & TRM: The Bridge TRM Skills Threat Management Error Management
Undesired State
Management

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