CENA 1 Safety Management in French CAA kFrom 91 to 95 in France k95 : EATCHIP safety policy kFrom 96 : a formal safety plan kWhere are we in 2000 ?

CENA 2 From 91 to 95 in France k91 : « CNSCA » was created : independent entity aiming at proposing measures that may avoid reproduction of assessed Airprox, thus reinforcing ATM safety kFirst output : in 92 creation of local « Quality and safety » units to assess airprox and STCA related incidents

CENA 3 Local safety unit kLocal Safety Commission H24 Safety indicators LSC - airprox - TCAS RA - STCA, d< 2,5 NM et h < 500 or 1000) -voluntary report - recommendations - annual report To local management Feedback for controllers

CENA 4 National safety organization H24 LSC - airprox - TCAS RA - STCA, -voluntary report - recommendations - annual report - CNSCA - Ministry of Transport schéma local Recommendations Annual report

CENA 5 Methods and tools

CENA 6 A taxonomy for causes kSystem failure (Hardware and Software) kRules and airspace organization kHuman factors : i Human error i Procedures violation i lack of proficiency i others kWorking methods and operational procedures

CENA 7 Nov 95 :EATCHIP SAFETY POLICY kAlmost all principles of the Policy were applied in France kIn particular were considered as adequate : i The incident reporting procedure (loss of separation type, Airprox, STCA, TCAS) i the incident analysis and associated lesson learning procedures including CNSCA kHowever, there was some doubt whether DNA had i «an explicit, pro-active approach to Safety management»

CENA : building up a safety action plan kHow do we perceive safety in France ?How do we perceive safety in France ? i Is there a safety policy ? Who is aware of it ? i How do we learn and what have we identified ? i What are our technical means and human resources ? kWhat should be achieved to comply with EATCHIP and have a more pro-active approach ? i List of actions kIs there a need to change the safety organization ? WG with 25 « experts », including Union representatives

CENA 9 Risk perception in French ATC kSafety level is excellent : 0 ACCIDENT ? 4,5% in air transport accidents kThe « real » problems in ATC : delays, strikes kBUT... i What about incidents as safety indicators? i What about controllers perception ? i What about the multiple and frequent changes ? It is difficult to manage safety in ultra-safe systems (R.Amalberti)

CENA 10 Risk Management in French ATC Optimistic… … or pessimistic ?

CENA 11 What we have learnt through incident analysis over the past decade i Is safety all about avoiding en-route air collision ? i Airprox rate quite steady, BUT recurrent causes i How to pick accident precursors in the database ? i New sources => new causes New sources => new causes i BUT : still unexplored areas The main causes : Human Factors!

CENA 12 New glasses : new picture kSTCA : < 5 NmkSTCA : < 2.5 Nm

CENA 13 Controllers are risk managers kExternal risk i safety margin kInternal risk i Confidence i Metaknowledge kHuman factors can degrade risk perception i being aware/ keeping track of one s own competence i over-confidence on data displayed i group pressure 1,5 NM 8 NM 5 NM 1,5 NM

CENA 14 What are the main threats in ATC ? kHuman factors ? i Situational Awareness, workload, teamwork i Attitudes towards rules and procedures i Hand-off, hand-over, sector splitting, sectors manning i Risk management : over confidence i Fatigue, stress, proficiency ? kFrequent changes impact on controllers risk management kOn ground operation, airspace organization i Runway incursion, IFR/VFR

CENA 15 DNA Safety Action plan Achieved in July 98

CENA 16 The chapters of DNA Safety Action plan lImplement the Safety Management structureImplement the Safety Management structure lBetter promote Air Navigation Safety Policy lBetter formalise Safety related proceduresBetter formalise Safety related procedures lImprove the incident reporting and analysis mechanismImprove the incident reporting and analysis mechanism lImprove experience feedback mechanismImprove experience feedback mechanism lImprove Safety trainingImprove Safety training lGive special attention to Safety nets lInvolve the staff representativesInvolve the staff representatives

CENA 17 Safety Management Organisation kA full time Safety manager was nominated at DNA level kNo Safety department was created at headquarters level kWithin each unit, a Safety Manager should be nominated i reports directly to the executive manager of the Organism i informs when needed the DNA Safety Manager i is responsible for the proper Safety Organisation within his Organism kNo formal allocation of Safety responsibilities

CENA 18 Better formalise Safety related procedures kEstablish local Safety plans kFormalise Safety analysis i Safety case for systems & procedures i Who validates, who signs ? kFormal management of operator manuals kFormalise experience feedback follow ups

CENA 19 Improve the incident reporting and analysis mechanism kIn line with directive i Insist on all significant incidents (not only loss of separation) i Non punitive environment (well known in ACC through STCA) kSet up differentiated incident analysis procedures kBuilding up a database with a new taxonomyBuilding up a database with a new taxonomy kModify relations with BEA kWork in co-operation with airlines

CENA 20 New taxonomy (INCA) k1- rules and procedures k2- hardware and software k3- environment k4- air-ground communications k5- ground-ground communications k6- teamwork k7- individual human factors k8- situational awareness k9- decision making

CENA 21 Improve feedback ? Decision Management Operational component Intrinsic component Recruiting Training Organization Procedures Tools Safety nets Traffic Events Failures... Workload Technical state Real organization Experience Feedback

CENA 22 What do we need as a feedback process ? kDefine a safety policy : a will to understand and a will to act kMore staff to tackle safety issues, more training, quicker answer kBetter cooperation from controllers through : i Education, trust towards safety staff, feedback kUse safety nets to trigger events Need to improve our safety culture

CENA 23 Improve training kSafety Management courses at ENAC kInclude TRM kUse tools like RITA kEnhance the training on emergency handling

CENA 24 Involve staff representatives kSome Safety matters examined in WG including staff representatives ] Operator manual ] QS manning ] Runway incursions ] Emergency handling ] Met information on radar screen ] Control units manning ]Positive feedback ] MSAW example

CENA 25 CAP 2001 Air Navigation Safety Folder kOrientation document drafted in spring 99 i by a group of motivated staff (not only management) kThe DNA has defined key actions j practical actions rather then philosophy j in line with the DNA Safety action plan j follow up managed by DGAC kAdoption : end 1999

CENA 26 The Chapters of the plan (1) kPromote Safety policy within DNA units kInsist on Safety tools for airports kEnhance feedback kReinforce QS units k Find ways to attract people k Merging technical and operational ? kInitial and continuous training

CENA 27 The Chapters of the plan (2) kHealth and Safety kFormalise procedures k Safety case k Operating manuals kSafety Capacity relation k Especially in case of contingency kSpecial attention to 2 recurrent factors k See and avoid limitations k manning of operational sectors

CENA 28 Where are we in 2000 ? From CENA studies (Safety and Human Factors approach)

CENA 29 Still some concerns… kSTCA implementation in TMA i Procedure definition : how to use it ? i Impact on risk visibility ? kResources needed for training i TRM i Emergency situations i Upgrade training on new systems kSafety issues in system design ? How can management get more involved in safety issues ?

CENA 30Conclusion kGood points : i Strategic plan : safety folder i Safety working group i More learning (database) i Progress in safety culture kQuestions : i Effect of safety structure on safety culture? i Still unexplored areas i What can be done with a growing set of events ? i Still difficult to be pro-active i Lack of human resources