Monitoring Normal Operations in ATC: The State of Affairs Captain Dan Maurino Captain Dan Maurino Flight Safety and Human Factors – ICAO First ICAO Global.

Monitoring Normal Monitoring Normal Operations in ATC:Operations in ATC:

The State of Affairs The State of Affairs

Captain Dan MaurinoCaptain Dan MaurinoFlight Safety and Human Factors – ICAOFlight Safety and Human Factors – ICAO

First ICAO Global Symposium on TEM & NOSS in ATCFirst ICAO Global Symposium on TEM & NOSS in ATCLuxembourgLuxembourg

9 – 10 November 20059 – 10 November 2005

Let’s face it, folks…We’re not rocket scientistsLet’s face it, folks…We’re not rocket scientists

The First Ultra-Safe Industrial SystemThe First Ultra-Safe Industrial System

Ultra-safe system (mid 1990’s onwards)Ultra-safe system (mid 1990’s onwards)Business management approach to Business management approach to

safety (SMS)safety (SMS)Routine collection and analysis of Routine collection and analysis of

operational data operational data

1010-3-3

1010-5-5

1010-7-7

Fragile system (1920’s -1970’s)Fragile system (1920’s -1970’s)Individual risk management & intensive trainingIndividual risk management & intensive trainingAccident investigationAccident investigation

Safe system (1970’s – mid 1990’s)Safe system (1970’s – mid 1990’s)Technology & regulationsTechnology & regulationsIncident investigation Incident investigation

NOSSNOSS

The Safety Data PictureThe Safety Data Picture Forensic systems – FailuresForensic systems – Failures

Accident investigationAccident investigationMajor incident Major incident

investigationinvestigation

Proactive systems – Monitoring Proactive systems – Monitoring normal operations normal operations Electronic data acquisition Electronic data acquisition

systems systems Voluntary self-reporting Voluntary self-reporting

systems systems Direct observation data Direct observation data

acquisition systems acquisition systems

Reactive systems – Reactive systems – AnomaliesAnomalies

Mandatory reporting Mandatory reporting systems systems Voluntary reporting Voluntary reporting

systems systems

System System designdesign

Baseline (ideal) performanceBaseline (ideal) performance

BaselineBaselineperformanceperformance

OperationalOperationalperformanceperformance

““PracticalPracticalDrift”Drift”

OperationalOperationaldeploymentdeployment

When the Book Goes Out of the WindowWhen the Book Goes Out of the Window

Operational ErrorsOperational Errors

TheThe safety safety consequencesconsequences of operational of operational errors depend errors depend on the on the context context where they where they take placetake place

BB

AA

Capturing the “drift”:Capturing the “drift”:context, not peoplecontext, not people

TEM & NOSS: Establishing the RelationshipTEM & NOSS: Establishing the Relationship

The features in operational context – The features in operational context – ThreatsThreats How the context influences what people do – How the context influences what people do – ErrorsErrors The results of the interaction between features in The results of the interaction between features in

operational context and of what people do – operational context and of what people do – Undesired statesUndesired states

TEM = Framework – TEM = Framework – What What we look forwe look for

NOSSNOSS =Tool – =Tool – HowHow we collect what we look for we collect what we look for The Ten Operating CharacteristicsThe Ten Operating Characteristics Normal ATC operationsNormal ATC operations

Capture an ATC system

Capture an ATC system realreal performance

performance

through the eyes of its ATCOs

through the eyes of its ATCOs

Safety Management – ICAO & IATASafety Management – ICAO & IATA Single event analysisSingle event analysis Integrated Threat Analysis (ITA) – ICAO & IATAIntegrated Threat Analysis (ITA) – ICAO & IATA Cabin Operations Safety Toolkit (Turbulence & Cabin Operations Safety Toolkit (Turbulence &

inadvertent slide deployment) – IATAinadvertent slide deployment) – IATA Auditing – NOSS & LOSA Auditing – NOSS & LOSA Training – Flight & Cabin Crew/ATCO (ICAO, IATA, ATS Training – Flight & Cabin Crew/ATCO (ICAO, IATA, ATS

providers and Airlines)providers and Airlines) Research and development (UT & Boeing)Research and development (UT & Boeing)

TEM Framework – Expanding Role TEM Framework – Expanding Role

TrainingTrainingFlight crewFlight crew

ATCOATCOCabin CrewCabin Crew

An Expanding RoleAn Expanding Role

SafetySafetyManagementManagement

R&DR&DUTUT

BoeingBoeing

AuditingAuditingLOSALOSANOSSNOSS

Error Error ManagementManagement

Threat Threat ManagementManagement

Undesired StateUndesired StateManagementManagement

ICAOICAO

ICAOICAO

State Letter AN 12/17- 05/93State Letter AN 12/17- 05/93

Aligned Safety Management ProvisionsAligned Safety Management Provisions Annex 6 – Operation of Aircraft, Parts I and IIIAnnex 6 – Operation of Aircraft, Parts I and III Annex 11 – Air Traffic ServicesAnnex 11 – Air Traffic Services Annex 14 – AerodromesAnnex 14 – Aerodromes A safety management “template”A safety management “template”

Safety programme – StatesSafety programme – States Safety management system – Operators/providersSafety management system – Operators/providers Acceptable level of safetyAcceptable level of safety

State Letter AN 12/17-05/93State Letter AN 12/17-05/93Aligned Safety Management ProvisionsAligned Safety Management Provisions Three basic safety management processesThree basic safety management processes

Hazard identificationHazard identification Remedial actionRemedial action Monitoring of effectiveness Monitoring of effectiveness

Direct accountability on the part of senior managementDirect accountability on the part of senior management ICAO Safety Management Manual (Doc 9859)ICAO Safety Management Manual (Doc 9859)

Normal operations monitoringNormal operations monitoring TEM, LOSA & NOSS TEM, LOSA & NOSS www.icao.int/anb/safetymanagement

State Letter AN 12/1.1-05/62State Letter AN 12/1.1-05/62

Annex 1 – Personnel LicensingAnnex 1 – Personnel Licensing Knowledge requirementsKnowledge requirements

Human performance Human performance including principles of threat and including principles of threat and error managementerror management

Operational procedures – Operational procedures – Application of threat and Application of threat and error management principles to operational error management principles to operational performanceperformance

Skills requirementsSkills requirements Recognize and manage threats and errorsRecognize and manage threats and errors

State Letter AN 12/1.1-05/62State Letter AN 12/1.1-05/62Annex 6 – Operation of aircraftAnnex 6 – Operation of aircraftChapter 9. Aeroplane Flight CrewChapter 9. Aeroplane Flight Crew9.3 – Flight crew member training programmes9.3 – Flight crew member training programmes

9.3.19.3.1 An operator shall establish and maintain a ground An operator shall establish and maintain a ground and flight training programme, approved by the and flight training programme, approved by the State of the operator…The training programme State of the operator…The training programme shall also include…training in knowledge and shall also include…training in knowledge and skills related to human performance skills related to human performance includingincluding threat and error management…threat and error management…The training The training programme shall be given on a recurrent basis…programme shall be given on a recurrent basis…

TEM & TRM: A Relationship Defined TEM & TRM: A Relationship Defined “…“…TEM is an TEM is an overarching safety concept with multiple overarching safety concept with multiple applications in aviationapplications in aviation; while TRM is exclusively a ; while TRM is exclusively a training training interventionintervention. The basic concepts underlying TEM (threats, errors . The basic concepts underlying TEM (threats, errors and undesired aircraft states) can be integrated – for example and undesired aircraft states) can be integrated – for example as an additional module – within existing TRM programmes. as an additional module – within existing TRM programmes. This is because TEM countermeasures build in part – although This is because TEM countermeasures build in part – although not exclusively – upon TRM skills. The combination of TEM not exclusively – upon TRM skills. The combination of TEM concepts with TRM skills thus introduces the opportunity to concepts with TRM skills thus introduces the opportunity to present the utilization of TRM skills by flight crews anchored in present the utilization of TRM skills by flight crews anchored in the operational environment, from an operational perspective. the operational environment, from an operational perspective. It It is emphasized that TEM is emphasized that TEM trainingtraining does not replace TRM training, does not replace TRM training, but rather complements and enhances it.”but rather complements and enhances it.”

TRMTRMSkillsSkills

Error ManagementError Management

Threat ManagementThreat Management

Undesired StateUndesired StateManagementManagement

TEM & TRM: The BridgeTEM & TRM: The Bridge

TEM & NOSS – ATC Safety Management Tools TEM & NOSS – ATC Safety Management Tools

EDAEDAVoluntary Voluntary ReportingReporting

Direct Direct observationsobservations