Safety Management in French CAA

1. Safety Management in French CAA • From 91 to 95 in France • 95 : EATCHIP safety policy • From 96 : a formal safety plan • Where are we in 2000 ? 1

2. From 91 to 95 in France • 91 : « CNSCA » was created : independent entity aiming at proposing measures that may avoid reproduction of assessed Airprox, thus reinforcing ATM safety • First output : in 92 creation of local « Quality and safety » units to assess airprox and STCA related incidents 2

3. Local safety unit • Local Safety Commission - recommendations - annual report To local management LSC Safety indicators - airprox - TCAS RA - STCA,d< 2,5 NM et h < 500 or 1000’) -voluntary report H24 Feedback for controllers 3

4. National safety organization Recommendations Annual report - Ministry of Transport - CNSCA - recommendations - annual report LSC - airprox - TCAS RA - STCA, -voluntary report H24 schéma local 4

5. Methods and tools 5

6. Nov 95 :EATCHIP SAFETY POLICY • Almost all principles of the Policy were applied in France • In particular were considered as adequate : • The incident reporting procedure (loss of separation type, Airprox, STCA, TCAS) • the incident analysis and associated lesson learning procedures including CNSCA • However, there was some doubt whether DNA had • «an explicit, pro-active approach to Safety management» 7

7. 96-97 : building up a safety action plan • How do we perceive safety in France ? • Is there a safety policy ? Who is aware of it ? • How do we learn and what have we identified ? • What are our technical means and human resources ? • What should be achieved to comply with EATCHIP and have a more pro-active approach ? • List of actions • Is there a need to change the safety organization ? WG with 25 « experts », including Union representatives 8

8. Risk Management in French ATC Optimistic… … or pessimistic ? 10

9. What we have learnt through incident analysis over the past decade • Is safety all about avoiding en-route air collision ? • Airprox rate quite steady, BUT recurrent causes • How to pick accident precursors in the database ? • New sources => new causes • BUT : still unexplored areas The main causes : Human Factors! 11

10. Controllers are risk managers 8 NM 1,5 NM 1,5 NM 5 NM • External risk • safety margin • Internal risk • Confidence • Metaknowledge • Human factors can degrade risk perception • being aware/ keeping track of one ’s own competence • over-confidence on data displayed • group pressure 13

11. What are the main threats in ATC ? • Human factors ? • Situational Awareness, workload, teamwork • Attitudes towards rules and procedures • Hand-off, hand-over, sector splitting, sectorsmanning • Risk management : over confidence • Fatigue, stress, proficiency ? • Frequent changes impact on controllers’ risk management • On ground operation, airspace organization • Runway incursion, IFR/VFR 14

12. DNA Safety Action plan Achieved in July 98 15

13. The chapters of DNA Safety Action plan • Implement the Safety Management structure • Better promote Air Navigation Safety Policy • Better formalise Safety related procedures • Improve the incident reporting and analysis mechanism • Improve experience feedback mechanism • Improve Safety training • Give special attention to Safety nets • Involve the staff representatives 16

14. Safety Management Organisation • A full time Safety manager was nominated at DNA level • No Safety department was created at headquarters level • Within each unit, a Safety Manager should be nominated • reports directly to the executive manager of the Organism • informs when needed the DNA Safety Manager • is responsible for the proper Safety Organisation within his Organism • No formal allocation of Safety responsibilities 17

15. Better formalise Safety related procedures • Establish local Safety plans • Formalise Safety analysis • Safety case for systems & procedures • Who validates, who signs ? • Formal management of operator manuals • Formalise experience feedback follow ups 18

16. Improve the incident reporting and analysis mechanism • In line with 94-56 directive • Insist on all significant incidents (not only loss of separation) • Non punitive environment (well known in ACC through STCA) • Set up differentiated incident analysis procedures • Building up a database with a new taxonomy • Modify relations with BEA • Work in co-operation with airlines 19

17. Improve feedback ? Decision Management Intrinsic component Tools Safety nets Organization Procedures Recruiting Training Experience Feedback Traffic Events Failures ... Technical state Workload Real organization Operational component 21

18. What do we need as a feedback process ? • Define a safety policy : a will to understand and a will to act • More staff to tackle safety issues, more training, quicker answer • Better cooperation from controllers through : • Education, trust towards safety staff, feedback • Use safety nets to trigger events Need to improve our safety culture 22

19. Improve training • Safety Management courses at ENAC • Include TRM • Use tools like RITA • Enhance the training on emergency handling 23

20. Involve staff representatives • Some Safety matters examined in WG including staff representatives • Operator manual • QS manning • Runway incursions • Emergency handling • Met information on radar screen • Control units manning • Positive feedback • MSAW example 24

21. CAP 2001 Air Navigation Safety Folder • Orientation document drafted in spring 99 • by a group of motivated staff (not only management) • The DNA has defined key actions • practical actions rather then philosophy • in line with the DNA Safety action plan • follow up managed by DGAC • Adoption : end 1999 25

22. Where are we in 2000 ? From CENA studies (Safety and Human Factors approach) 28

23. Still some concerns… • STCA implementation in TMA • Procedure definition : how to use it ? • Impact on risk visibility ? • Resources needed for training • TRM • Emergency situations • Upgrade training on new systems • Safety issues in system design ? How can management get more involved in safety issues ? 29

24. Conclusion • Good points : • Strategic plan : safety folder • Safety working group • More learning (database) • Progress in safety culture • Questions : • Effect of safety structure on safety culture? • Still unexplored areas • What can be done with a growing set of events ? • Still difficult to be pro-active • Lack of human resources 30