Presentation on theme: "Marcus Knauer Airservices Australia First ICAO TEM & NOSS Symposium Luxembourg 9 & 10 November 2005 Marcus Knauer Airservices Australia First ICAO TEM."— Presentation transcript:
Marcus Knauer Airservices Australia First ICAO TEM & NOSS Symposium Luxembourg 9 & 10 November 2005 Marcus Knauer Airservices Australia First ICAO TEM & NOSS Symposium Luxembourg 9 & 10 November 2005
Introduction Who we are Preparation for the Trial The Trial Trial results Action Taken Lessons Learned
Melbourne FIR Brisbane FIR Mauritius Johannesburg Oceanic Antananarvio Seychelles Male Jakarta Bali Biak Oakland FIR Port Moresby Honiara Nauru Nadi (Fiji) Auckland Oceanic NZ Colombo Mumbai Manila FIR South East Asia & Indian Ocean Airspace
Air Traffic Statistics The Australian FIRs Approximately 11% of the worlds 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
Equator Australian Airspace Honiara High level Airspace ( under Contract) Airspace controlled by Airservices Australia Approx 5000NM Hawaii (3 Control Towers) Guam & Saipan (2 Control Towers) Nauru High Level Airspace ( under Contract)
Comparisons – Australian Airspace / Europe
Why are we here? Member of ICAO NOSS Study Group. Undertook First Operational NOSS Trial April – May Share our experience.
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
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.
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.
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
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
TAAATS Controller Workstation Air Situation Display (ASD) Auxiliary Display Voice Switching and Control System (VSCS) Weather Radar
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. 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.
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. 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 werent one offs but were prevalent in every day operations. –Normal behaviours What we saw
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.
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. Whats Happened to date?
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.
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