Greg Down 2 nd ICAO Global TEM & NOSS Symposium FAA – Washington, DC Normal Operations Safety Surveys The NAV CANADA Experience.

Greg Down

2nd ICAO Global TEM & NOSS SymposiumFAA – Washington, DC

Normal Operations Safety SurveysThe NAV CANADA Experience

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PresentationOverview

• NOSS Trials

• Post-NOSS Activities

• Lessons Learned

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NOSS Activities

• 2005-06 Vancouver ACCEnroute NOSS Trial

• 2006-07 Vancouver ACCTerminal NOSS Trial

• 2007 Gander ACC NOSSPlanned for 2007

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Image of Vancouver FIR

Vancouver FIR

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2005 Enroute NOSS Overview

• 3 Enroute Specialties

• 13 Sectors

• 7 Observers

• 57 Observations

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• Project Planning

• Observer Selection and Training

• Observation Period

• Data Verification

• Data Analysis

• Final Report Presentation

2005 Enroute NOSS Overview

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Final Report Presentation

• Provided to (in order):– Local Management– Senior Management and

Union Executive– Observers– Staff

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Final Report Presentations - Staff

• Allowed controllers to hear directly what the process was– what was observed– what the data meant

• Opportunity to voice their concerns about the system

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• High level of staff buy-in of the process and the feedback provided

• Controllers wanted the opportunity to fully participate/collaborate on the solutions

Final Report Presentations

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What do we do now?

The Safety Change Process

• Will depend on individual unit / organization as how best to interpret and implement change

• We looked at various means:– Recurrent training– Procedures teams– Airspace design– Staff meetings– Intra-specialty meetings– Quality Assurance process improvement– Steering Committee

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The Safety Change Process

• Post-NOSS Steering Committee

• Consisted of:

– one management representative

– the NOSS Project Manager

– one observer from each Specialty

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Post-NOSS Committee

Identified Targets for Enhancement based upon the feedback from :

– NOSS Trial Final Report– Threat / Error / Undesired State Logs– Observer Narratives– Feedback from Data Verification

participants– Feedback received from observers,

controllers and management at the NOSS Briefings

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We elected to address several items :– Controller focus groups– Airspace design changes– “Position Hand-over Briefing

Checklists”– Environmental changes– “Other Controller” Threat

Training

Targets For Enhancement

Lessons Learned

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Involvement of the Union – Critical

• Reassures and legitimizes the process for controllers

• Assistance in selecting observers who are respected and capable

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Communicate Communicate Communicate

• The biggest controller concerns were related to lack of knowledge about NOSS

• Importance of preparing the supervisors

• Be present and available to answer any and all questions

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Except that people often don’t actually listen…

• You will do a lot of explaining as observations begin

• Deal with issues as they occur

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REFUSALS - Actually a good thing

• A clear indication of the strength of the program

• Controllers quickly saw that there was no response for refusing a NOSS observation

• As a result, there were no additional refusals

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“STOP” Rules

• Provided further evidence of the seriousness that NOSS treats controller anonymity

• A couple of examples: – TCAS R/A– pilot altitude bust

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Observer Selection

• Imperative that are they are respected and trusted

• Pick a variety of backgrounds and experience levels

• Used controllers who weren’t already involved in many other things (“fresh faces”)

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Don’t burn out your observers

• Space out the observations

• …but not too much

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Data Verification

• Phenomenal insight into your operation

• Tremendous amount of work

• One of the greatest learning experiences about your operation

• Did I mention the work part...?

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CLOSING & REVIEW

“NOSS aims to capture how the system is behaving as opposed to how it was designed to function”

• Draft ICAO NOSS Manual

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