1. Airservices Australia The NOSS Experience Airservices Australia The NOSS Experience Marcus Knauer – NOSS Project Manager

2. Why are we here? Member of ICAO NOSS Study Group Undertook First Operational NOSS Trial April – May 2005 Incorporated into Business Operations May 2006

3. Current Data Sources Electronically Submitted Incident Reports –Incidents –Events Technical Fault Reporting Audits –Regulator/Internal – compliance Check and Training assessments Operational Risk Assessments Hazard Identification and Risk Analysis WHY NOSS?

4. NOSS Implementation Scope Snapshot of Brisbane/Melbourne Operations and Brisbane, Sydney and Melbourne Towers Centres 18 Groups –Upper Airspace, Transitional Enroute and Terminal Towers 3 Towers –Aerodrome Control and Surface Movement Control

5. Centres & Towers Observed Brisbane Centre Brisbane Tower Melbourne Centre Melbourne Tower Sydney Tower

6. Comparisons – Australia / USA

7. What we did Project Steering Committee Controller Association briefing Joint Management/Union sponsorship All controllers received TEM briefing Publicised project and its intent –Created a NOSS web pageCreated a NOSS web page –Internal News letters Expressions of Interest - Observers were jointly endorsed by management and union

8. Project Scope 14 Observers – 9 from centres, 5 from towers 1 week Observer Training –Theoretical knowledge, 2 trial observations, debrief session 8 weeks Data Collection –201 observations in centres –128 observations in towers –Approximately 360 hours 2 Weeks Data Verification –UT, Project Manager, Observer, Union representative and Procedures specialist

9. Centre Threat & Error Summary ERRORS Most Prevalent Checklists Incomplete/Inaccurate information display Full readback not obtained Computer/Automation Input Error Most Consequential Incomplete/Inaccurate Information display Not passing operational information Coordination Errors THREATS Most Prevalent R/T Communications Airspace Other Controllers Equipment/Software Most Consequential Controller Distraction Pilot Readback Error Equipment/Software Coordination

10. Procedural Variation across both Centres, all Groups and Towers Checklists not being adhered to Non operational conversation Controller display not reflecting actual control state What we saw - Centres

11. Greater number of undesired states in one of the centres –70% of all undesired states (46% of observations) Overall –Inaccurate representation of Traffic/Airspace –Critical information not passed/coordinated –Inaccurate HMI –Lack of Separation Assurance –Aircraft not in contact with ATC –Aircraft not in possession of important information What we saw - Centres

12. Tower Threat & Error Summary ERRORS Most Prevalent Phraseology Readbacks Flight Progress Strips Most Consequential Incomplete Inaccurate information display Flight Progress Strip Manipulation THREATS Most Prevalent R/T Communications Other Controllers Equipment/Software Most Consequential Other Controller Error Equipment/Software Pilot readback Errors Pilot failure to respond to calls

13. What we saw - Towers Checklists not being used Runway Crossing procedures inconsistent –Runway Incursion Action Plan Flight Progress Strip Errors Unnecessary software messages distracting Aerodrome Controller Not monitoring takeoff/landing Full readbacks not being obtained

14. Tower 1 –Converging Runway Operation (Traffic Information, Visual Separation aircraft not on frequency) Tower 2 –Poor phraseology leading to lack of Separation Assurance on taxiway, not using procedure blocking strip Tower 3 –Not having RWY occupied strip Undesired State in other two towers What we saw - Towers

15. Validated incident reports and incident investigation findings. Causal factors in recent incidents the same Controller behaviour was exhibited during NOSS Identified systemic issues as well as issues which were location specific in both towers and centres Overall

16. Lessons Learned Association engagement Scheduling of observations with training Observer Selection Observer overload Controller refusals – testing the waters Briefings to staff –Level of appropriate detail

17. NOSS Value Provides Lead Indicators –Identifying Incident Precursors Enable development of proactive interventions rather than being reactive Focus of resources Intangible Benefits Validated Gut feeling

18. Whats Happened to date? Tangible Particular errors in Groups who participated in Trial last year, significantly reduced same type of error NOSS Action plan Developed Intangible Observers adopting practices witnessed during observations, taking them back to their group – capturing good practice

19. Where to next? Publish findings to staff with action plan Initiate Safety Change - Implementation of NOSS action planImplementation of NOSS action plan Collaborate with airlines, other ANSPs Develop Threat and Error Management training program for controllers using NOSS data –Check Supervisors

20. Additional Uses of NOSS Data Integration into organisations Operational Risk Assessments Enhance Incident Investigation process Exchange of data/issues with airlines –Opportunity to address industry issues

21. Questions? ThankYou

22. Action Plan Based broadly on Targets for Enhancement Immediate ActionsAdditional Facility Specific ActionsRaw Data Ongoing StrategiesAnalysis CHALLENGE - Managing the Safety Change Process