1、Doc 9910 AN1473 Normal Operations Safety Survey (NOSS) Approved by the Secretary General and published under his authority First Edition - 2008 International Civil Aviation Organization Copyright International Civil Aviation Organization Provided by IHS under license with ICAONot for ResaleNo reprod
2、uction or networking permitted without license from IHS-,-,-Doc 9910 AN1473 Normal Operations Safety Survey (NOSS) Approved by the Secretary General and published under his authority First Edition - 2008 International Civil Aviation Organization Copyright International Civil Aviation Organization Pr
3、ovided by IHS under license with ICAONot for ResaleNo reproduction or networking permitted without license from IHS-,-,-Published in separate English, Arabic, Chinese, French, Russian and Spanish editions by the INTERNATIONAL CIVIL AVIATION ORGANIZATION 999 University Street, Montreal, Quebec, Canad
4、a H3C 5H7 For ordering information and for a complete listing of sales agents and booksellers, please go to the ICAO website at www.icao.int First edition 2008 ICAO Doc 9910, Normal Operations Safety Survey (NOSS) Order Number: Doc9910 ISBN 978-92-9231-1 53-7 0 ICAO 2008 All rights reserved. No part
5、 of this publication may be reproduced, stored in a retrieval system or transmitted in any form or by any means, without prior permission in writing from the International Civil Aviation Organization. Copyright International Civil Aviation Organization Provided by IHS under license with ICAONot for
6、ResaleNo reproduction or networking permitted without license from IHS-,-,-AMENDMENTS Amendments are announced in the supplements to the Catalogue of ICAO Publications; the Catalogue and its supplements are available on the ICAO website at www.icao.int. The space below is provided to keep a record o
7、f such amendments. RECORD OF AMENDMENTS AND CORRIGENDA AMENDMENTS No. Date Entered by Copyright International Civil Aviation Organization Provided by IHS under license with ICAONot for ResaleNo reproduction or networking permitted without license from IHS-,-,-TABLE OF CONTENTS Page Foreword Acronyms
8、 and abbreviations . Introduction . Chapter I . Background and justification . 1 . 1 A brief description of Normal Operations Safety Survey (NOSS) . 1.2 Framework for NOSS 1.3 NOSS and the organizational safety framework . 1.4 NOSS operating characteristics . 1.5 Resources required for conducting a
9、NOSS . 1.6 Benefits of NOSS . Chapter 2 . Preparing for a NOSS Association and management endorsement Project steering committee . Role of the NOSS project manager Promotion campaign . NOSS target selection Scope of the NOSS . Duration of the NOSS Time frame for the NOSS . Language for the NOSS . .
10、Observer selection . Observation protocols . Data storage and protection Preparing to receive and act upon the NOSS report Briefings of affected groups Chapter 3 . Observer training and data collection . 3.1 Observer training overview 3.2 Background knowledge and observer training . 3.3 General guid
11、elines . 3.4 The use of NOSS forms . 3.5 The use of codes 1 3.6 The narrative 3.7 Structuring the narratives . 3.8 Data de-identification Copyright International Civil Aviation Organization Provided by IHS under license with ICAONot for ResaleNo reproduction or networking permitted without license f
12、rom IHS-,-,-(vi) Normal Operations Safety Survey (NOSS) Page 3.9 NOSS managementlstaff interface . 3.10 Observer support during observations Chapter 4 . Data verification process 4.1 Purpose of the data verification process . 4.2 Description of the data verification process 4.3 Composition of the da
13、ta verification group . 4.4 Unusable data Chapter 5 . Data analysis and production of the final report . 5.1 Analysing the data 5.2 Writing the report 5.3 Outline for the NOSS report . Chapter 6 . Using the NOSS results in the organization . General Presentation of the NOSS report to the organizatio
14、n . Managing the NOSS report Selecting targets for safety enhancements . Use of the NOSS data for comparative purposes . Evaluation of the NOSS project in the organization Conducting a follow-up NOSS Conducting another NOSS at a different location andlor with a different target . Appendix A . Threat
15、 and error management (TEM) in air traffic control Appendix B . NOSS observation forms and code books . Appendix C . Executive summary Appendix D . Sample support letter . Appendix E . Attributes of the NOSS facilitator and the data analyst . Appendix F . Pre-NOSS checklist . A-I B-I F-I Copyright I
16、nternational Civil Aviation Organization Provided by IHS under license with ICAONot for ResaleNo reproduction or networking permitted without license from IHS-,-,-FOREWORD The safety of civil aviation is the major objective of the International Civil Aviation Organization (ICAO). Considerable progre
17、ss has been made in securing one of the highest levels of safety in contemporary socio-technical production systems, but additional improvements in safety are considered necessary. It has long been known that the majority of aviation safety breakdowns result from less than optimum interaction betwee
18、n the different components of the aviation system and the people who operate that system and serve as a last line of defence to preserve aviation safety. Therefore, any advance in this regard can have a significant impact on the improvement of aviation safety. This was recognized by the ICAO Assembl
19、y, which in 1986 adopted Resolution A26-9 on Flight Safety and Human Factors. As a follow-up to that Assembly Resolution, the Air Navigation Commission formulated the following task: “To improve safety in aviation by making States more aware and responsive to the importance of Human Factors in civil
20、 aviation operations through the provision of practical Human Factors materials and measures, developed on the basis of experience in States, and by developing and recommending appropriate amendments to existing material in Annexes and other documents with regard to the role of Human Factors in the
21、present and future operational environments. Special emphasis will be directed to the Human Factors issues that may influence the design, transition and in-service use of the future ICAO CNSIATM systems.“ One of the methods chosen to implement Assembly Resolution A26-9 was the publication of guidanc
22、e material, including manuals and a series of digests that address various aspects of Human Factors and their contribution to aviation safety. These documents are intended primarily for use by States to increase the awareness of their personnel about the contribution of Human Factors and human perfo
23、rmance to aviation safety. The target audience is managers both of civil aviation administrations and industry, including safety, training and operational managers. The target audience also includes regulatory bodies, safety and investigation agencies and training establishments, as well as senior a
24、nd middle non-operational industry management. The publication of this manual is furthermore a result of Recommendation 215 of the Eleventh ICAO Air Navigation Conference, held in Montreal in 2003, which reads: “That ICAO initiate studies on the development of guidance material for the monitoring of
25、 safety during normal air traffic service operations, taking into account, but not limited to, the line operations safety audit (LOSA) programmes which have been implemented by a number of airlines.“ This manual introduces the Normal Operations Safety Survey (NOSS), a methodology for capturing safet
26、y data during normal air traffic control (ATC) operations. The NOSS methodology is based on the Threat and Error Management (TEM) framework and is a safety management tool to monitor safety during normal aviation operations. Monitoring safety in normal operations is an essential activity within the
27、safety management systems of air traffic services (ATS) provider organizations, and NOSS is proposed as a suitable way to do this. In introducing NOSS, the manual also presents the latest information available to international civil aviation on the control of systemic error in operational environmen
28、ts, from the perspective of safety management. Its target audience includes senior safety, training and operational personnel in ATS and regulatory bodies. Copyright International Civil Aviation Organization Provided by IHS under license with ICAONot for ResaleNo reproduction or networking permitted
29、 without license from IHS-,-,-ACC ADC ATC ATCO ATS ATSP CAA CNSIATM EUROCONTROL FAA ICAO IFATCA LOSA NOSS OJT R/T RVSM SMC SMS TEM TLC VFR ACRONYMS AND ABBREVIATIONS Area control centre Aerodrome control Air trafic control Air traffic control officer Air traffic services Air traffic services provide
30、r Civil aviation authority Communication, navigation and surveillancelair traffic management European Organisation for the Safety of Air Navigation Federal Aviation Administration International Civil Aviation Organization International Federation of Air Traffic Controllers Associations Line operatio
31、ns safety audit Normal Operations Safety Survey On-the-job-training Radiotelephony Reduced vertical separation minima Surface movement control Safety management system Threat and Error Management The LOSA collaborative Visual flight rules Copyright International Civil Aviation Organization Provided
32、by IHS under license with ICAONot for ResaleNo reproduction or networking permitted without license from IHS-,-,-INTRODUCTION 1. Aviation is arguably the safest mode of mass transportation and one of the safest socio-technical production systems in the history of humankind. This achievement acquires
33、 particular relevance when considering the age of the aviation industry, which is measured in decades, as compared to other industries whose histories span centuries. It is a tribute to the aviation safety community and its unrelenting endeavours that in a mere century aviation has progressed, from
34、a safety perspective, from a fragile system to the first ultra-safe system in the history of transportation. 2. In retrospect, the history of the progress of aviation safety can be divided into three distinct eras, each with fundamentally different attributes. 3. In the first era, which spans from t
35、he pioneering days of the early 1900s until approximately the late 1960s, from a safety standpoint aviation could be characterized as a fragile system. Safety breakdowns, although certainly not daily occurrences, were not infrequent. It was then only logical that safety understanding and prevention
36、strategies were derived mainly from accident investigation. The safety focus was on individuals and individual risk management, which in turn built upon the foundations provided by intensive training programmes. 4. During the second era, from the early 1970s until the mid-1990s, aviation became a sa
37、fe system. The frequency of safety breakdowns diminished significantly, and a more all-encompassing understanding of safety, which looked beyond individuals to the broader system, was progressively developed. This naturally led to a search for safety lessons beyond accident investigation, and thus t
38、he emphasis shifted to the investigation of incidents. This shift to a broader perspective of safety and incident investigation was accompanied by the massive introduction of technology as the only way to achieve increased system production demands, and an ensuing multiple-fold increase in safety re
39、gulations. 5. From the mid-1990s to the present day, aviation entered its third safety era, becoming an ultra-safe system (i.e. a system that experiences less than one catastrophic safety breakdown in every one million production cycles). Overall, accidents became infrequent to the extent of turning
40、 into anomalies in the system. Incidents became fewer and far apart. Thus, the broad systemic safety perspective that had started to emerge during the previous era was further pursued using a business-like approach to the management of safety, based upon the routine collection and analysis of daily
41、operational data. This business-like approach to safety underlies the introduction of safety management systems (SMS). Figure 1-1 illustrates the evolution of safety discussed above. 6. The evolution in safety thinking was accompanied by an evolution in terms of sources of safety data and safety dat
42、a collection. Up until the mid-1990s, safety data collection was mostly reactive. Eventually what began as “forensic“ systems for safety data collection, in which the data were derived from the investigation of accidents and major incidents, developed into systems where safety data from less severe
43、events became available through mandatory and voluntary reporting programmes. Nevertheless, these newer systems were still reactive: safety data became available only after safety deficiencies triggered a certain event or occurrence. 7. In observing the business-like approach to safety underlying SM
44、S, it became evident that in order to sustain safety in the ultra-safe system, a proactive data collection methodology, to complement the existing reactive systems, was required. To that end, electronic data acquisition systems and non-jeopardy self-reporting programmes were introduced to collect sa
45、fety data from normal operations. The latest addition to these proactive safety data collection methodologies are data acquisition systems that are based on direct observation of operational personnel during normal operations. Copyright International Civil Aviation Organization Provided by IHS under
46、 license with ICAONot for ResaleNo reproduction or networking permitted without license from IHS-,-,-(xii) Normal Operations Safety Sunley (NOSS) Figure 1-1. The evolution of safety in aviation The First Ultra-Safe Industrial System 8. There is solid justification for collecting safety data from nor
47、mal aviation operations. In spite of its safety excellence, the aviation system, just like any other human-made system, is far from perfect. Aviation is an open system, i.e. it operates in an uncontrolled environment and is subject to environmental disturbances. It is simply not feasible to design f
48、rom scratch an open system that is perfect, if for no other reason than that it is impossible to anticipate all potential operational interactions between people, technology and the context in which aviation operations take place. 10“ I 04 1 o7 9. System designers anticipate plausible scenarios of o
49、perational interactions, and thus an initial system design can be conceptually thought of as a solid straight line that embodies the three basic assumptions of system design: the technology needed to achieve the system production goals; the training necessary for people to operate the technology; and the regulations that dictate system
