1. 1 NOSS – the trial(s) in Europe Alexander Skoniezki, Head of Safety, Security and Human Factors Division on behalf of Manfred Barbarino, Human Factors Domain Manager (DAP/SSH) - EUROCONTROL - manfred.barbarino@eurocontrol.int European Organisation for the Safety of Air Navigation

2. 2 Trial Objectives 2006/2007 2-3 Trials in European ANS Providers NOSS - does it work in Europe ? Lessons learned Areas of Improvement Input NOSS Study Group Input ICAO NOSS manual

3. 3 NOSS Context – Managing ATM Threats & Errors Analysis & Learning ATM Threats & Errors Prevention Mitigation & Coping Team Resource Management Error Analysis e.g. HERA/JANUS Critical Incident Stress Management ICAO Normal Operations Safety Survey HF in Safety Management Systems

4. 4 First European Trial – FINAVIA in 2006 ATC Sites ANS Centre – Tampere Airport – Helsinki 6 Observers 4 ACC + 2 TWR/APP Each 9 -12 Observations 63 Observations Total = 54 h 25 min 10 NOSS Operating Characteristics applied EUROCONTROL Data Collection Site EUROCONTROL Project Manager + Training Facilitator NOSS Trial ACC 41 x Approach 9 x Tower 13 x

5. 5 FINAVIA NOSS Trial - Timeline Presentation FINAVIA Management Action Plan Sites Visit Briefings Workforce & Unions PR – Material Local co-ordinator Observers Training Real Time Support Observations within 2 weeks Data Verification Phase Data Analysis + Report Writing Final Report + Feedback Session March 2006 May 2006 August 2006 September 2006 October 2006 December 2006

6. 6 Observation Results - Overall 63 Observations 511 Threats 176 Errors 26 Undesired States 41 ACC 13 TWR 9 APP Limited Samples Results to be treated with some caution !

7. 7 Observation Results - Statistics 63 Observations 54 hrs 25 min M = 65 min each 511 Threats (T) M = 8.1 T per observation 176 Errors (E) M = 2.8 E per observation 26 Undesired States (US) M = 0.7 US per observation 475 (93%) - managed 46 (7%) - mismanaged 168 (95%) - managed 8 (5%) - mismanaged 25 (96%) - managed 1 (4%) - mismanaged

8. 8 Observation Results – Event Coding Taxonomy Level III Threat Code Airspace Penetration Level I Threat Category Airborne Threat Level II Threat Type A/C Pilot Issue Threats Level II Error Code Incorrect Readback Level I Error Type Communication E. Errors Level I U. State Code Incomplete HO/TO Undesired States

9. 9 Observation Results – Threat Types

10. 10 The NOSS observers coded 511 Threats 93% of observed Threats managed Most frequent Threats: - ACC setting - Threats internally generated by the organisation - Tower setting - Threats generated by airborne side activity Threats caused by other controllers most frequent Twenty Threats related to position relief or opening/closing of a position Most of these were associated with the Threat Type Other controller Observation Results – Summary Threats

11. 11 Observation Results – Error Types

12. 12 Observation Results – Summary Errors The NOSS observers coded 176 Errors 95% of observed Errors managed Most frequent Errors: - Related to communication - Related to procedures Procedure Errors most likely to lead to further errors or undesired states Sixteen Errors linked to position relief or opening/closing of position Errors in communication appear to be the biggest challenge at handover

13. 13 Observation Results – Undesired States Undesired StateACCApproachTower Inaccurate representation of traffic (1) 100 Unable to effectively monitor traffic on ground (8) 011 Incomplete HO / TO (2) 100 Traffic situation not being monitored (3) 100 Equipment failure (5) 100 Lack of separation assurance (50) 22 1 Deviation from route clearance (51) 4 00 RWY/TWY not verified to be clear for progress (53) 011 Airspace penetration (54) 2 00 Restricted airspace not protected (55) 100 Frequency congestion (56) 001 Aircraft is lined up on wrong runway/ wrong position (57) 00 2 Traffic congestion due to blocked taxi (58) 00 3 Total 26 1349

14. 14 Observation Results – Undesired States The NOSS observers coded 26 Undesired States 96% of Undesired States managed One Undesired State was mismanaged High proportion of Undesired States were accounted for by Tower - Traffic congestion leading to blocked taxi-way Eleven Undesired States seem to relate to airborne separation

15. 15 Examples – Good Practices (Helsinki) There are two runway crossings (via ZD and Y) and one intersection departure (ZG) at the same time. As ZG departing ATR is starting its take- off, second aircraft is cleared to cross runway. Controller did not specify this time the crossing intersection, which could alarm pilots in ATR as they are just departing. Generally controllers would be expected to specify intersection - this represents a good practice. Updating the SMR display for departing flights by dragging identification from list to targets needs focusing and distracts from other more essential duties. Good practice to be able to do this if one has the time. The handover is dealt very well, all the affecting things are mentioned and the previous controller stays a while afterwards and asks then whether its ok for him to leave.

16. 16 Lessons Learned: Strengths Organisations buy-in - communication & marketing essential + Workforce – accepted the NOSS approach easily + Observers - found process easy to understand and to use + Observers - able to capture safety related performance + Results - likely to provide useful data for safety improvements +

17. 17 Lessons Learned: Issues Few observations for Tower and Approach - Observation Narratives: English was not first language - Codes for Threat, Error, Undesired States: Need major adaptation - Capturing good practices within NOSS is very limited - Reliability of observations and validity of data -

18. 18 FINAVIA Follow-up Next steps Analysis of NOSS report and narratives Safety recommendations and actions Monitoring execution of safety actions Redoing NOSS in 2009/2010 ??? Trend Analysis NOSS 1 vs. NOSS 2

19. 19 NOSS – R&D Topics Proposed NOSS R&D Topics Reliability & validity of NOSS observations NOSS+ (e.g. post observation interviews) NOSS coding - customisation + benchmarking Cost-benefit studies Cultural and language differences

20. 20 NOSS in Europe – Way Forward NOSS in Europe Possible Next Steps 2 additional NOSS trials in 2007/2008 NOSS promotional material NOSS workshop NOSS facilitator training NOSS user group