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 ?

1CENA

Safety Management in French CAASafety Management in French CAA

From 91 to 95 in France

95 : EATCHIP safety policy

From 96 : a formal safety plan

Where are we in 2000 ?

2CENA

From 91 to 95 in FranceFrom 91 to 95 in France

91 : « CNSCA » was created : independent entity aiming at proposing measures that may avoid reproduction of assessed Airprox, thus reinforcing ATM safety

First output : in 92 creation of local « Quality and safety » units to assess airprox and STCA related incidents

3CENA

Local safety unitLocal safety unitLocal safety unitLocal safety unit Local 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

4CENA

National safety organizationNational safety organizationNational safety organizationNational safety organization

H24

LSC

- airprox- TCAS RA- STCA,-voluntary report

- recommendations- annual report

- CNSCA

- Ministry of Transport

schéma local

RecommendationsAnnual report

5CENA

Methods and toolsMethods and toolsMethods and toolsMethods and tools

7CENA

Nov 95 :EATCHIP SAFETY POLICYNov 95 :EATCHIP SAFETY POLICY

Almost all principles of the Policy were applied in France

In particular were considered as adequate :The incident reporting procedure (loss of separation type,

Airprox, STCA, TCAS)the incident analysis and associated lesson learning

procedures including CNSCA However, there was some doubt whether DNA had

«an explicit, pro-active approach to Safety management»

8CENA

96-97 : building up a safety action 96-97 : building up a safety action planplan

How do we perceive safety in France ? Is there a safety policy ? Who is aware of it ?How do we learn and what have we identified ?What are our technical means and human resources ?

What should be achieved to comply with EATCHIP and have a more pro-active approach ?List of actions

Is there a need to change the safety organization ?

WG with 25 « experts », including Union representatives

10CENA

Risk Management in French ATCRisk Management in French ATC

1000000

1200000

1400000

1600000

1800000

2000000

1988 1989 1990 1991 1992 1993 1994 1995 1996 1997

0

10

20

30

40

50

60

70

80

90

100

TRAFIC IFR AIRPROX IFR/IFR

0

500000

1000000

1500000

2000000

2500000

1988 1989 1990 1991 1992 1993 1994 1995 1996 1997

10

15

20

25

30

35

40

TRAFIC IFR AIRPROX IFR/IFR

Optimistic…

… or pessimistic ?

11CENA

What we have learnt through incident What we have learnt through incident analysis over the past decadeanalysis over the past decade

Is safety all about avoiding en-route air collision ?Airprox rate quite steady, BUT recurrent causesHow to pick accident precursors in the database ?New sources => new causesBUT : still unexplored areas

The main causes : Human Factors!

13CENA

Controllers are risk managers Controllers are risk managers

External risk safety margin

Internal riskConfidenceMetaknowledge

Human factors can degrade risk perceptionbeing aware/ keeping track of

one ’s own competenceover-confidence on data

displayedgroup pressure

1,5 NM

8 NM

5 NM

1,5 NM

14CENA

What are the main threats in ATC ?What are the main threats in ATC ?

Human factors ?Situational Awareness, workload, teamworkAttitudes towards rules and proceduresHand-off, hand-over, sector splitting, sectors manning Risk management : over confidenceFatigue, stress, proficiency ?

Frequent changes impact on controllers’ risk management

On ground operation, airspace organizationRunway incursion, IFR/VFR

15CENA

DNA Safety Action DNA Safety Action planplan

Achieved in July 98

16CENA

The chapters of DNA Safety Action plan The chapters of DNA Safety Action plan

Implement the Safety Management structure Better promote Air Navigation Safety Policy Better formalise Safety related procedures Improve the incident reporting and analysis

mechanism Improve experience feedback mechanism Improve Safety training Give special attention to Safety nets Involve the staff representatives

17CENA

Safety Management OrganisationSafety Management Organisation

A full time Safety manager was nominated at DNA level No Safety department was created at headquarters levelWithin each unit, a Safety Manager should be nominated

reports directly to the executive manager of the Organism

informs when needed the DNA Safety Manageris responsible for the proper Safety Organisation

within his OrganismNo formal allocation of Safety responsibilities

18CENA

Better formalise Safety related Better formalise Safety related proceduresprocedures

Establish local Safety plans Formalise Safety analysis

Safety case for systems & proceduresWho validates, who signs ?

Formal management of operator manuals Formalise experience feedback follow ups

19CENA

Improve the incident reporting and Improve the incident reporting and analysis mechanismanalysis mechanism

In line with 94-56 directiveInsist on all significant incidents (not only loss of separation)Non punitive environment (well known in ACC through STCA)

Set up differentiated incident analysis procedures Building up a database with a new taxonomy Modify relations with BEA Work in co-operation with airlines

21CENA

Improve feedback ?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

22CENA

What do we need as a feedback What do we need as a feedback process ?process ?

Define a safety policy : a will to understand and a will to act

More staff to tackle safety issues, more training, quicker answer

Better cooperation from controllers through : Education, trust towards safety staff, feedback

Use safety nets to trigger events

Need to improve our safety culture

23CENA

Improve trainingImprove training

Safety Management courses at ENAC

Include TRM

Use tools like RITA

Enhance the training on emergency handling

24CENA

Involve staff representatives Involve staff representatives

Some Safety matters examined in WG including staff representativesOperator manualQS manningRunway incursionsEmergency handlingMet information on radar screenControl units manning

Positive feedback MSAW example

25CENA

CAP 2001 Air Navigation CAP 2001 Air Navigation Safety FolderSafety Folder

Orientation document drafted in spring 99 by a group of motivated staff (not only

management) The DNA has defined key actions

practical actions rather then philosophy in line with the DNA Safety action plan follow up managed by DGAC

Adoption : end 1999

28CENA

Where are we in 2000 ?Where are we in 2000 ?

From CENA studies (Safety and Human Factors approach)

29CENA

Still some concerns…Still some concerns…

STCA implementation in TMAProcedure definition : how to use it ?Impact on risk visibility ?

Resources needed for trainingTRMEmergency situationsUpgrade training on new systems

Safety issues in system design ?

How can management get more involved in safety issues ?

30CENA

ConclusionConclusion Good points :

Strategic plan : safety folderSafety working group More learning (database)Progress in safety culture

Questions :Effect of safety structure on safety culture?Still unexplored areasWhat can be done with a growing set of events ?Still difficult to be pro-activeLack of human resources