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introduction of the procedures;
b) use simulation to develop and evaluate the new procedures;
c) implement changes in small, easily manageable steps to allow confidence to be gained that the
procedures are suitable; and
d) commence changes in periods of low traffic density.
17.3.4 As outlined in Chapter 13, risk assessment of ATS procedures is best conducted by a group
including:
a) those responsible for procedure design;
b) staff with current knowledge and experience of the procedural area under assessment, i.e. system
users — ATS personnel and pilots to assess the procedures from an operational perspective;
c) engineering specialist — to provide expert opinion on equipment performance;
d) safety/risk specialist — to guide the application of the methodology; and
e) Human Factors specialist.
17.3.5 Appendix 1 to Chapter 13 provides guidance for the conduct of group hazard identification and
assessments sessions which are particularly effective in the identification and analysis of potential hazards
in ATS procedures.
17.3.6 Appendix 2 to this chapter provides further guidance for the risk assessment of ATS
procedures.
17.4 THREAT AND ERROR MANAGEMENT
17.4.1 As discussed in Chapter 16, the Threat and Error Management (TEM) framework assists in
understanding, from an operational perspective, the interrelationship between safety and human
performance in dynamic and challenging operational contexts. While threats to operational safety have long
been recognized, the principles of TEM make it possible to manage the three basic components of the TEM
framework: threats, errors and undesired states.
17.4.2 Threats and errors are a normal part of everyday operations. To prevent them from
degenerating into undesired states, ATCOs must routinely manage such threats and errors. To maintain
safety margins in ATC operations, ATCOs must also manage any undesired state that may arise from such
threats and errors. These actions may offer the last opportunity to avoid an unsafe outcome.
Chapter 17. Air Traffic Services (ATS) 17-9
17.4.3 Threats, errors and undesired states must all be managed within a set of contextual
complexities. For example, controllers must deal with adverse meteorological conditions, airports
surrounded by high mountains, congested airspace, aircraft malfunctions, and errors committed by other
people outside of the ATC room such as flight crew, ground staff or maintenance workers. The TEM model
considers these complexities as threats because they all have the potential to negatively affect ATC
operations by reducing margins of safety.
17.4.4 Appendix 3 to this chapter examines TEM in ATS in more detail.
17.5 NORMAL OPERATIONS SAFETY SURVEY (NOSS)
17.5.1 Until recently, safety monitoring relied on staff identifying actual or potential hazards to the safe
operation of the system, and submitting reports. If unsafe practices have become part of the normal method
of operating, it is unlikely that the staff involved would recognize these as being unsafe and file reports
through the safety occurrence reporting system.
17.5.2 Observation-based methods provide an additional means of gathering data that does not rely
on the individuals involved. Several airlines have introduced a programme called Line Operations Safety
Audit (LOSA) to monitor flight operations under normal operating conditions. (LOSA is described more fully
in Chapter 16.)
17.5.3 LOSA is a proven method for identifying hazards and for developing coping strategies for
normal flight deck operations. The aim of the monitoring is to gather data on operational threats, crew errors,
and their management. The observations are made by observers, trained in LOSA techniques, sitting in the
jump seat on regular scheduled flights. By monitoring normal operations, much can be learned about pilots’
successful strategies for managing normal threats, errors and undesirable states.
17.5.4 The lessons of LOSA are being applied to ATC. However, because ATC operations differ
significantly from flight operations, the evolving methodology, known as Normal Operations Safety Survey
(NOSS), will differ too. The idea behind NOSS is to provide the ATC community with a means for obtaining
robust data on threats, errors and undesired states. Analysis of NOSS data, together with safety data from
conventional sources, should make it possible to focus the safety change process on the areas that need
attention the most.
17.5.5 NOSS builds on the TEM framework. In its simplest form, NOSS involves over-the-shoulder
observations during normal shifts. Analysis of these normative data in conjunction with data acquired
through other means (such as incident reporting schemes and occurrence investigations) should provide
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Safety Management Manual (SMM) 安全管理手册(132)
