comparing threats and errors from losa and noss ......comparing threats and errors from losa and...
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Comparing threats and errors from LOSA and NOSS programs conducted in AustraliaChris Henry, NOSS CollaborativePatrick Murray, LOSA Collaborative
Organisation Logo
Our Background
LOSA / NOSS Operating Characteristics 1. Peer-to-peer observations during real-time
operations
2. Anonymous, confidential, and non-punitive data collection
3. Joint management / association support
4. Voluntary Participation
5. Trusted and trained observers
6. Trusted and secure data collection site
7. Systematic data collection instrument based on TEM
8. Data verification process
9. Data-derived targets for safety enhancement
10. Feedback results to front line operators
LOSA Collaborative AirlinesAegean AeroMexico Air Astana Air Canada
Air Central Air France Air Freight New Zealand Air Hong Kong
Air Japan Air Nelson Air New Zealand Air Next
Air Nippon Air Nippon Network Air Niugini Air Transat
Alaska Airlines All Nippon Airways ANA/JP Express Asiana Airlines
Atlantic Southeast Airlines Avianca Braathens Cathay Pacific
Chautauqua Airlines China Airlines Continental Airlines Continental Micronesia
Copa Airlines Delta Air Lines DHL Air Dragonair / Cathay Dragon
Emirates Etihad ExpressJet FedEx
Firefly Frontier Airlines Hawaiian Airlines Horizon Air
IndiGo Japan Airlines JetBlue KLM
LACSA Malaysia Airlines Mexicana Mount Cook Airlines
Qatar Airways Republic Airlines Royal Air Maroc Royal Jordanian
Saudia Shuttle America SilkAir Singapore Airlines
Singapore Airlines Cargo Southwest Airlines TACA International TACA Peru
TAP Portugal Thomas Cook Airlines Transavia United Airlines
UPS Virgin America Virgin Australia Volaris
WestJet Jeju Air Hong Kong Express
LOSA Collaborative Activity – 22,000 flights
LOSA Threats Defined• External events that occur outside the influence of the pilots but which
require their attention to maintain safety marginsEnvironmental Threats
Adverse Weather
Airport
ATC Environmental Ops Pressure
Terrain Traffic Communication
Systemic Airline Threats
• Airline Operational Pressure
• Aircraft
• Cabin
• Dispatch / Paperwork
• Ground / Ramp
• Ground Maintenance
NOSS Collaborative Activity NOSS Archive – 5,000+ observations from the following
countriesAustraliaNew ZealandCanada United States of America South Korea South Africa ThailandUnited Arab EmiratesIreland
Several new ANSPs are planning for implementation in 2019/20
Frequent non-airline threats
• Restricted airspace: Enroute & Terminal saw elevated prevalence of restricted airspace
• Minimal impact • Occasionally delayed / impacted weather deviations
• Non RPT traffic (Parachuting, surveys, med flights, military flights)• Significantly increased complexity• Disproportionately a source of pilot communication & performance threats
• Airspace design• Crossing points require tactical intervention
Most common threats in AustraliaTowers Approach High Density Enroute
Incomplete readback Incomplete readback Pilot did not respond to callFrequency congestion (especially on ground) Pilot did not respond to call Incomplete readback
Pilot did not respond to call Incorrect readback Incorrect readback
Incorrect / Truncated call sign Pilot did not report required information Incorrect / Truncated call sign
Incorrect readback No / Wrong ATIS reported Frequency congestion
NOSS: Most Common Pilot Communication Threats in OZ
NOSS: Most Common Pilot / Aircraft Performance Threats in OZMost common threats in Australia
Towers Approach High Density Enroute
Gate not accessible (particularly SYD) Pilot provides wrong information CFL & inputted level disagreement
Transponder issue (non RPTs) CFL & inputted level disagreement Flight planning issue (non RPTs)
RWY occupied longer than expected Nonstandard pilot requests (e.g. cancel requirements, atypical approaches)
Pilot provides wrong information
Pilot taxi error Airspace violations (non RPTs) Non RVSM aircraft in RVSM band
Aircraft equipment issue Pilot deviation from clearance (speeds = RPTs, others = non RPTs) Closing speeds / Overtake
Aircraft not ready at threshold Rate of climb / descent Rate of climb / descent
Closing speeds / Overtake
Pilot communication & performance threats – Why?
• Pilots missing calls• Incomplete readbacks – via SID / STAR, altitudes, RWY at SYD• RWY occupied longer than expected – slow to roll, missed exit, slow taxi speed• Pilot taxi errors – miss turn, turn at wrong point• CFL & inputted level disagreement – ATR limitation / procedure?• Slow rate of climb / descent – level of during IVAs at SYD, CLAM alerts
Clearance instructions – how much is too much?• Frequent LOSA threat in Australia (and elsewhere) – 3 or more clearances
in one call.• ANSPs do not have explicit procedures about how much information can be
given in a single call
Discuss – how much is too much?• Why is ATC issuing instructions in such a manner?• What impact does this have on flight crews?
Late landing clearance below 1,000ft• Frequent LOSA threat in Australia
• Why is this happening?
• How does it impact flight crews?
• What other threats or errors by ATC or flight crews might be contributing?
Late landing clearance below 1,000ft• Some controllers have said any airport where landing clearances can be given before
1,000ft needs an efficiency review • Others have expressed a belief that controllers are not fulling applying Reduced Runway
Separation Minima (RRSM) to ensure flight crews receive landing clearances prior to 1,000ft.
• ATC will often tell crews to expect a late landing clearance. Helpful?
• Discuss!
Stable by 1000 ft IMC or 500 ft VMC
• Fully Configured
• Checklist complete
• Speed between +10 and -5 target speed
• Sink rate no greater than 1000 fpm
• Vertical: No greater than 1 dot off GS
• Lateral: No greater than 1 dot off LOC
Unstable Approaches – Definition (From FSF ALARS)
ICAO Pilot Competencies (Emerging data)
Areas of Competency Underpinned by Knowledge
Air Traffic Control Competencies - ICAO Doc 10056 (2016)Situational Awareness
Traffic & Capacity ManagementSeparation & Conflict Resolution
CommunicationCoordination
Management of Non-Routine SituationsProblem Solving & Decision Making
Self-Management & Continuous DevelopmentWorkload Management
TeamworkAreas of Competency
Underpinned by Knowledge