Comparing threats and errors from LOSA and NOSS programs conducted in AustraliaChris Henry, NOSS CollaborativePatrick Murray, LOSA Collaborative

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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