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

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

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

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

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

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

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

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

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.

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

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

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 www.icao.int/anb/safetymanagement

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

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…

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.”

TEM & TRM: The Bridge TRM Skills Threat Management Error Management Undesired State Management

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