1. Airservices Australia First ICAO TEM & NOSS Symposium
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
Seychelles
Jakarta
Port
Moresby
Nauru
Bali
Honiara
Nadi
(Fiji)
Brisbane FIR
Antananarvio
Mauritius NZ
Melbourne FIR
Johannesburg Oceanic
Auckland
Oceanic

4. Air Traffic Statistics
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
/day
Melbourne FIR
Brisbane FIR
Honiara
Nauru

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

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

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!