1. NOSS Trial May / June 2005 Experience

2. Format Brief History of Airways NZ Safety Culture Why we ran the trial Preparation for the Trial Conduct of the trial Management viewpoint Observers viewpoint Staff viewpoint (as told by an observer) Presentation of the Report Main findings Action Plan to address issues Summary of NOSS for Airways Questions

3. CEO Perspective video

4. Airways Loss of Separation Incidents per 100,000 Movements

5. Main Trunk Managers perspective video

6. Advantages of NOSS for Airways The use of TEM framework gave far greater structure than our Position Checks NOSS would allow a broader view of the organisation as a whole We saw potential to adopt TEM in other areas e.g. incident investigation The base concept was already well proven through LOSA which was being used by most of our major customers The analytical support offered by the UT was significant to a small organisation Clear guidelines, processes and forms were being developed by ICAO The potential to gain from the experience of other providers The potential for benchmarking

7. Summary of Key Factors High level management support Union buy in Budget $30,000NZD Support from ICAO in the form of draft procedures Technical and analytical support from the UT

8. Staff Communications Update on Airways involvement in the ICAO working group and general introduction to the NOSS and LOSA Discussion on TEM principles General update on the proposed trial, including a union endorsement Notice from senior management formally announcing the trail and highlighting their support and expectations Reminder that the trial is about to start

9. Observer Qualities Professional Credibility –Not just experience –Not Checkers –Some were quite junior –Integrity Analytical Relatively open minded –Many controller can be quite rigid in their thinking Enthusiasm and passion –Wanted people who would promote and sell the process

10. Video Tim 1 Tim Training Video

11. Video Tim First Observation

12. Slide Terminal Suite DeparturesArrivalsPlanner Typical Terminal Radar Suite

13. Co-OrdSMCTower Typical Tower Layout

14. Tim Staff Perspective video

15. Tim Data Cleaning

18. Error Management 76% of 165 errors had inconsequential outcomes 22% led to an undesired state 2% led to additional error Total 40 errors mismanaged Error Management 76% of 165 errors had inconsequential outcomes 22% led to an undesired state 2% led to additional error Total 40 errors mismanaged Threat Prevalence 100% of observations had at least one threat Total 363 threats observed Threat Prevalence 100% of observations had at least one threat Total 363 threats observed Threat to Error Linkage 44% of 165 errors were linked to mismanaged threat 56% of errors were not Threat to Error Linkage 44% of 165 errors were linked to mismanaged threat 56% of errors were not Threat Management 82% of 362 threats were effectively managed 18% were mismanaged Total 65 threats mismanaged Threat Management 82% of 362 threats were effectively managed 18% were mismanaged Total 65 threats mismanaged Threats - Undesired State Linkage 7% of threats were linked to undesired states 63% of 40 undesired states were linked to threats Threats - Undesired State Linkage 7% of threats were linked to undesired states 63% of 40 undesired states were linked to threats Error Prevalence 81% of observations had at least one error 19% were error free Total 165 errors were observed Error Prevalence 81% of observations had at least one error 19% were error free Total 165 errors were observed Detected Error Outcomes 74% of errors that were detected were inconsequential 22% were linked to undesired states 4% were linked to additional error Detected Error Outcomes 74% of errors that were detected were inconsequential 22% were linked to undesired states 4% were linked to additional error Undesired State Prevalence and Management 45% of observations had US Total 40 USs 100% of 40 US were inconsequential Undesired State Prevalence and Management 45% of observations had US Total 40 USs 100% of 40 US were inconsequential Error Response 13% of 165 errors were detected by the observed controller 20% were detected by another party 67% went undetected or were ignored Error Response 13% of 165 errors were detected by the observed controller 20% were detected by another party 67% went undetected or were ignored Undetected Error Outcomes 76% of errors that were detected were inconsequential 22% were linked to undesired states 2% were linked to additional error Undetected Error Outcomes 76% of errors that were detected were inconsequential 22% were linked to undesired states 2% were linked to additional error Total 63 observations 41% Airborne -Readback errors -Failure to respond -Parachuting near BDY 35% ANSP -Distractions,conversation -Incorrect co-ordination 23% Environmental -WX deviations -Low / poor visibility Overall R/T comms produced the most threats and occurred on 70% of Obs 76% of 165 errors had inconsequential outcomes 22% lead to Undesired states 2% lead to an additional error 40 Undesired states equally spread across the sectors observed -Lack of separation assurance -Strip board layout All 40 were managed 67%of errors went undetected or were ignored 82% of all Threats were managed 18% were mismanaged The most mismanaged threats were those posed by other controllers 81% of observations had at least 1 error 165 errors in Total Co-ordination errors were the most common

19. Countermeasures 14% of the observations received a marginal rating for post-handover support. 11% received a marginal rating for workload management. Generally late opening of additional positions Not restricting traffic flow. –Interestingly those controllers who received marginal ratings in this area also encountered more threats and had more mismanaged threats and errors than other controllers

20. Recommendations 12 were made, 11 have been accepted for action e.g. –Setting up working group with the airspace users to address Airborne / ground threats e.g. Similar callsigns, visual approaches etc –Address co-ordination issues through TRM –Mandate degraded mode training in annual cyclic training –Review hand-off procedures in some sectors –Adopt formal HO/TO procedures across all sectors(Checklists) –Review opening and closing position procedures through cyclic training –Review traffic complexity issues within specific sectors –Increase training on ATS systems