Presented to: By: Date: Federal Aviation Administration The ATO and Safety: Improving Our Safety...
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Transcript of Presented to: By: Date: Federal Aviation Administration The ATO and Safety: Improving Our Safety...
Presented to:
By:
Date:
Federal AviationAdministration
The ATO and Safety: Improving Our Safety Culture
ATO Safety Service
Aerospace Guidance and Control Systems Committee (AGCSC) – Lake Tahoe, NV
3/2/2006
Joe Schanne, Director IOT&E
The ATO and Safety2Federal Aviation
AdministrationMarch 2, 2006
DISCUSSION TOPICS:
• Overview (Who am I??? …. Who am I representing??)
• Maintaining/Enhancing Safety in U.S Air Traffic Control
• Safety Management System (SMS) and Safety Culture
The ATO and Safety3Federal Aviation
AdministrationMarch 2, 2006
International Models• FAA’s new Air Traffic Control (ATC) provider/regulator model is
consistent with international models– SMS functions within and is the responsibility of the service provider (ATO)
– Oversight (at varying levels) is outside of provider (in AVS)
Oversight: Transport Canada
Service: NAV CanadaOversight: CAA
Service: NATS
Oversight: Federal
Ministry of Transport
Service: DFS
Oversight: CASA
Service: Airservices Australia
The ATO and Safety4Federal Aviation
AdministrationMarch 2, 2006
FAA Safety Organizations
Administrator& Deputy Administrator
Air TrafficServices
Subcommittee
Chief Operating OfficerATO Transition
CommunicationsOperationsPlanning
FinanceAcquisition &Bus. Services
En Route &Oceanic Terminal Flight Services
SystemOperations
TechnicalOperations
Associate Administratorfor Aviation Safety (AVS)
Air Traffic Organization (ATO)Air Traffic Organization (ATO)
ATO Safety Service
Manage SMS process Support safety risk
management (SRM) Monitor/assure NAS
safety through: Audits/evaluations Data/metric
analyses Promote safety Collaborate
internationally Primary interface with
AOV
Provide independent safety oversight of air traffic service provision
Audit of process, not daily operations
Can require a change to enhance safety
AOV
Safety
Communication
The ATO and Safety5Federal Aviation
AdministrationMarch 2, 2006
Safety …. Our Highest Priority
The ATO
Safety. Service. Value.
The ATO and Safety6Federal Aviation
AdministrationMarch 2, 2006
FAA Safety Management System
Assurance
Policy
Safety Promotion
Architecture
SMS Requirements
SMS Responsibilities & Accountabilities
Safety Oversight
Safety Risk Management (SRM) - e.g., changes are safe
SRM Filter (what changes require SRM?)
SRM Guidance
SRM Documentation (and who approves?)
Safety Assurance and Evaluations
Safety Data Tracking and Analysis Recommending Actions
based on Safety Metrics
SMS Training
Safety Organization
Safety Culture
Safety Lessons Learned
The ATO and Safety7Federal Aviation
AdministrationMarch 2, 2006
FAA Safety Management System (SMS)
Assurance
Policy
Safety Promotion
Architecture
Safety Risk Safety Risk Management (SRM)Management (SRM)
An Example ….
Unmanned Airborne Systems (UAS’s)
The ATO and Safety8Federal Aviation
AdministrationMarch 2, 2006
SRM Example ..UAS Challenges
Ensuring safety of the U.S. NAS– Users and public on the ground
Minimizing safety impacts:
– Inherent low visibility of many UAS aircraft - more difficult to visually detect and track
– Increased time between detection and avoidance
– UAS aircraft performance limits in collision avoidance
Differentiating between Recreational model aircraft and UAS aircraft
Supporting the national defense expanding access requests
The ATO and Safety9Federal Aviation
AdministrationMarch 2, 2006
See and Avoid is not an ATC Function Radar does not depict everything in the NAS
The ATO and Safety10Federal Aviation
AdministrationMarch 2, 2006
Within “segregated” airspace– Includes Special Use Airspace (SUA) Restricted and Prohibited
areas & Air Traffic Control Assigned Airspace (ATCAA)– Excludes MOA, MTR’s and Warning areas
In non-segregated airspace– “Public” UAS – through Certificate of Authorization (COA) process– “Civil” UAS – using experimental / type certification process– “Model” aircraft – with guidance from AC 91-57, dated June 1981– Variety of other operations believed to be occurring by both the public and
private sector• Some based on interpretations of “model” aircraft guidance • Others with a lack of knowledge of aviation environment requirements
While ensuring “no harm” to other NAS customers and public
Current UAS Operations in the NAS
The ATO and Safety11Federal Aviation
AdministrationMarch 2, 2006
DOD UAS Border Flight – Arizona (Hunter UA)
Altitude: 11,000 to 13,000 MSLDimensions: 105 NM x 10 NM
The ATO and Safety12Federal Aviation
AdministrationMarch 2, 2006
Safety Risk Management
Assurance
Policy
Safety Promotion
Architecture
Improving Safety Improving Safety CultureCulture
An Example ….
The ATO and Safety13Federal Aviation
AdministrationMarch 2, 2006
The primary purpose of the ATC system is to prevent a collision….
Tenerife Accident: March 27, 1977
The ATO and Safety14Federal Aviation
AdministrationMarch 2, 2006
What is a Safety Culture?A Safety Culture includes:
– Personal dedication and accountability
• Individual attitudes and behaviors
– Shared vision with structures to attain it
• Organizational processes, methods and metrics
– Commitment to improve (resist complacency)
• Beyond simple adherence to procedures
• Learning and continuous improvement
– Pervasive safety thinking
• Commitment to excellence
• Integration of safety into all activities
Leaders must:– Create a climate in which news is quickly and easily communicated,
– Be committed to investing the time and resources to address risk
The ATO and Safety15Federal Aviation
AdministrationMarch 2, 2006
Potential Challenges to Evolving the Safety Culture
• Complacency based on past success• Belief that the organization is as advanced as possible• Data questioned rather than acknowledging need for
change• History of mistrust and hiding information• Facilities penalized for reporting errors• Difficulty in breaking through the bureaucracy• Resistance to change; Cynicism
The ATO and Safety16Federal Aviation
AdministrationMarch 2, 2006
We Have Data, But We Are Reactive, Not Proactive
Eva
luat
ion
s
Inve
stig
atio
ns1
AircraftAccident
~30Incidents
~300HazardousConditions
~1,000Unreported
“Unsafe Acts”R
un
way
Incu
rsio
ns/
Op
erat
ion
al E
rro
rs
NTSBNTSB
DOT IGDOT IG
AVS/AOVAVS/AOV
(OE/RI, etc.)(OE/RI, etc.)
(TCAS Alerts, UCRs, Non-Compliance,(TCAS Alerts, UCRs, Non-Compliance, Go-arounds, Bad Documentation, etc.)Go-arounds, Bad Documentation, etc.)
(Non-Reported OEs/ODs, Missed Checks, etc.)(Non-Reported OEs/ODs, Missed Checks, etc.)
The ATO and Safety17Federal Aviation
AdministrationMarch 2, 2006
Examples
• We have previously discussed the NASA Challenger Disaster and how complacency crept back in before Columbia.
• Recent Discovery flight showed willingness to do the right thing, even when not the popular thing to do.
• An ATC Example: Überlingen Collision Video–Credit: DFS Deutsche Flugsicherung GmbH
The ATO and Safety18Federal Aviation
AdministrationMarch 2, 2006
Überlingen Collision Video
The ATO and Safety19Federal Aviation
AdministrationMarch 2, 2006
Example …. Überlingen Accident Überlingen Accident July 1, 2002July 1, 2002
• Unreported, Unknown to management
• Aircraft Accident
• Previous OE by this controller in similar circumstances
• TCAS procedures not integrated internationally
• Management allowed mid-shift operations with one controller working both HIGH altitude and LOW altitude workstations. There was no complete situation display.
• Ongoing resectorization activity:• Controllers did not read Notice • Radar in a back-up mode, no Conflict Alert• Communication system impaired
Accident
Incidents
HazardousConditions
Unreported“Unsafe Acts”
The ATO and Safety20Federal Aviation
AdministrationMarch 2, 2006
Lack of Management Oversight
• Reduced staffing on midnight shift • Tolerated a policy of “extended breaks” on mids• Became complacent, failed to compensate for loss
of automation with human redundancy• Failed to ensure own regulations were followed:
– Single person operations required full automation capabilities– The reduced communication service was not coordinated with
adjacent facilities as required– Failed to ensure controllers reviewed “Facility NOTICE” posted
about reduced capabilities on the night of the accident
The ATO and Safety21Federal Aviation
AdministrationMarch 2, 2006
… An Update …
Monument on the grave of Vitaly Kaloyev's wife and two children, Diana, 4, right, Konstantin, 10, and Svetlana, 44, in the city of Vladikavkaz, southern Russia, in this Feb. 27, 2004 file photo. Swiss prosecutors are urging a Zurich court, Switzerland to convict Russian man Vitaly Kaloyev of stabbing the air traffic controller he believed was responsible for the death of his wife and two children in a mid-air collision.
The ATO and Safety22Federal Aviation
AdministrationMarch 2, 2006
Where do you think you are?• Questions to indicate health of the Safety Climate
– Are employees committed to safety and ready to apply the resources necessary?
– Do employees feel encouraged to point out possible problems?
– Do employees fear retaliation for exposing problems?
– Does management show that they want to know the problems?
– Are Safety positions seen as a career boost, not a dead-end?
• If improvement is necessary, what can be done to improve?
The ATO and Safety23Federal Aviation
AdministrationMarch 2, 2006
Safety Culture Evolution
*Adapted from Safeskies 2001, “Aviation Safety Culture,” Patrick Hudson, Centre for Safety Science, Leiden University
PATHOLOGICALWho cares as long as we’re not caught
Chronically Complacent
REACTIVESafety is important. We do a lot every
time we have an accident
CALCULATIVEWe have systems in place to manage all
hazards
PROACTIVEAnticipating and preventing problems
before they occur
GENERATIVESafety is how we do business around
hereConstantly Vigilant
Increasing Tru
stIncreasing A
wareness
The ATO and Safety24Federal Aviation
AdministrationMarch 2, 2006
A Final Thought …
All truth passes through three stages:
– First, it is ridiculed.
– Second, it is violently opposed.
– Third, it is accepted as being self-evident.(Arthur Schopenhauer, 19th Century Philosopher)
As a Leader/Manager, how do you respond when As a Leader/Manager, how do you respond when a safety “truth” is brought to you?a safety “truth” is brought to you?