Threat and Error Management (TEM) & Normal Operations Safety Survey (NOSS)

Chris Henry, Ph.D.The University of Texas Human Factors Research Project

The University of Texas at Austin

IFATCA Asia-Pacific Meeting

TEM & NOSS: Background and TEM & NOSS: Background and

DevelopmentDevelopment

LOSA AirlinesLOSA Airlines

Aeromexico Continental Express Mt. Cook Airlines (New Zealand)

Alaska Airlines Continental Micronesia Regional Express (Australia)

All Nippon Airways

Air Canada

Delta Airlines

DHL – UK

Saudi Arabian Airlines

Singapore Airlines

Air New Zealand EVA Air Silk Air (Singapore)

Air Transat Emirates Skyway / Midwest Connect

Asiana Frontier Airlines (USA) TAP Portugal

Braathens (Norway) Japan Airlines TACA / TACA Peru

Cathay Pacific LACSA (Costa Rica) UNI Air (Taiwan)

China Airlines QANTAS US Airways

COPA (Panama)

Continental

Malaysia Airlines

Mexicana

Westjet

Over 8,000 observations, 35 airlines, 20 countries

TEM & NOSS DevelopmentTEM & NOSS Development

� The ICAO NOSS Study Group� Federal Aviation Administration

� Airservices Australia

� Airways New Zealand

� NAV CANADA

� EUROCONTROL

� ICAO

� International Federation of Air Traffic Controllers’ Associations

� Civil Aviation Authority - United Kingdom

� DFS (Germany)

� University of Texas

� TEM = Framework - What we look for

� NOSS = Tool - How we capture what we are looking for

TEM Terminology for ATCTEM Terminology for ATC

� Threats: Events or errors that occur beyond the influence of the air traffic controller, increase operational complexity, and which must be managed to maintain the margins of safety

� Errors: Actions or inactions by the air traffic controller that lead to deviations from organisational or controller intentions or expectations

� Undesired States: Operational conditions where an unintended traffic

situation results in a reduction in margins of safety

Contributions to SMSContributions to SMS

Aviation Safety EnvelopeAviation Safety Envelope

Safety

Incidents

Accidents

Normal Operations

Safety Data CoverageSafety Data CoverageAccidents

Incidents

Normal Operations

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Voluntary Incident Reports

NOSS

Accident InvestigationMandatory Incident Reports

NOSS Success FactorsNOSS Success Factors

NOSS Success FactorsNOSS Success Factors

� NOSS success is dependent upon methodology and execution

Low controller trust = Low quality data because there will be no differentiation between

NOSS and proficiency checks

AngelPerformance

Natural

Performance

Evaluation Nobody

NOSS Observer

- NOSS value +- +

- Controller Trust +- +

NOSS: Gaining Controller TrustNOSS: Gaining Controller Trust

1. Over-the-shoulder observations during normal shifts

2. Joint management / association sponsorship

3. Voluntary Participation

4. Trusted and trained observers

5. Anonymous, confidential, and non-punitive data collection

6. Trusted and secure data collection site

7. Systematic data collection instrument

8. Data verification process

9. Data-derived targets for safety enhancement

10. Feedback results to controllers

NOSS DefinedNOSS Defined

� The 10 characteristics that differentiate NOSS (LOSA) from other methodologies have been endorsed by the:� International Civil Aviation Organization� International Air Transport Association� International Federation of Airline Pilots’ Associations� International Federation of Air Traffic Controllers’ Associations� Federal Aviation Administration� US Airline Pilots Association� The LOSA Collaborative

� University of Texas

� Programs that omit one or more of the characteristics might be useful and beneficial, but they are not NOSS/LOSA

� NOSS must have all ten characteristics

NOSS Case Study NOSS Case Study –– Cataloguing and Cataloguing and

Addressing the Threats (Stressors)Addressing the Threats (Stressors)

Bay Sector Bay Sector –– Not a Happy PlaceNot a Happy Place

� Bay sector had a reputation of being an

unstructured and challenging piece of airspace

� NOSS results substantiated the reputation

� More threats, mismanaged threats, errors, and undesired states in Bay than other sectors

� Conflictions, parachute activity, training aircraft, little airspace for vectoring

� Impartial observers agree, the sector is a mess!

One sector in particular that was previously recognized as being

unstructured, and containing a high number of threats was

confirmed by the NOSS data to the point that a formal review was

initiated. I would have to say it was not NOSS alone that lead to

the review, but the factual information it provided gave

considerable weight that lead to the final decision. Since the

review the sector has undergone some wide ranging changes from

changes in the management structure to improved procedures for

controllers at the coalface

-- Provided by the manager of the airspace in question

Response to FindingsResponse to Findings

Bay Sector Bay Sector –– A Much Happier Place A Much Happier Place

� Solutions suggested (and adopted) by staff:

� Dedicated parachute activity that reduced demands on

controller

� Circular flow route introduced

� Confines of controlled airspace increased to give more options/flexibility to controller

NOSS Findings NOSS Findings –– Safety ContributionsSafety Contributions

� Identify threats within the operating environment

� Check the quality/usability of procedures

� Understand controller shortcuts and workarounds

� Assess the degree of transference of training to the line

� Identify problems with controller/equipment interfaces

� Make comparisons across units or facilities

� Assess safety margins & base rates

NOSS Findings NOSS Findings –– Areas of ApplicationAreas of Application

� Procedures

� Training

� Workspace

� Automated Tools

� Airspace Design

� Airline / ANSP information exchange