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ATC management with a means for focusing the safety change process on those threats which most erode
the margins of safety in the ATC system.
17.5.6 NOSS recognizes that controllers routinely manage the threats, errors and undesired states
that they face each day during the course of normal operations. Their timely intervention preserves the
desired margins of safety — before an unsafe outcome (i.e. an accident or incident arises). Understanding
how effective controllers deal with the evolving situation is vital to developing the necessary
countermeasures to preserve defences within the ATS system. Since safety management strategies are
best directed against systemic threats rather than individual errors, the primary objective of NOSS must be
to identify threats, not just to count errors.
17.5.7 At the time of writing this manual, the protocols for applying NOSS in an actual work
environment have yet to be determined.
— — — — — — — —
17-APP 1-1
Appendix 1 to Chapter 17
HUMAN FACTORS ISSUES AFFECTING
HUMAN PERFORMANCE IN AIR TRAFFIC SERVICES1
1. Listed below are some of the more common Human Factors issues affecting human performance in
the provision of ATS:
a) Physiological limitations:
1) vision — the ability to physically see events unfolding (e.g. from a control tower);
2) hearing — the ability to discriminate different speech patterns in a noisy environment; and
3) chronic fatigue affecting judgement, cognitive skills and memory;
b) Psychological variables:
1) memory (essential to maintaining a three-dimensional picture of a dynamic situation);
2) vigilance versus distractions and boredom;
3) operating pressures (e.g. from supervisors, management and peers);
4) motivation and frame of mind (perhaps affected by domestic or other outside pressures);
5) stress tolerance (and consequential stress-related illnesses);
6) judgement;
7) habit patterns (e.g. taking procedural shortcuts); and
8) cultural diversity of the many users of the ATS system (such as military versus civilian, different
companies, foreign versus domestic, and different languages and behavioural patterns) — all
potentially capable of affecting the controllers’ expectancy;
c) Equipment factors:
1) display design and workstation layout;
2) user-friendliness of software, including flexibility to adapt to changing situations; and
3) use of automation;
1. See the Human Factors Training Manual (Doc 9683) for a more complete discussion of human performance in ATS.
17-APP 1-2 Safety Management Manual (SMM)
d) Information transfer problems:
1) frequency congestion;
2) call sign confusion;
3) hearing expectancy;
4) language comprehension and accent; and
5) use of non-standard phraseology;
e) Workload considerations:
1) volume and complexity of traffic;
2) number of sectors in use;
3) situational awareness (maintaining the “big picture”);
4) mental models used in decision-making (e.g. “rules of thumb”);
5) time since last break;
6) impact of shift work, scheduling and overtime; and
7) chronic fatigue; and
f) Organizational factors:
1) corporate safety culture;
2) approach to teamwork (and use of team resource management (TRM));
3) adequacy of training;
4) controller experience, competence and currency;
5) quality of first-line supervision;
6) controller/management relationship;
7) effective standardization of procedures and phraseology; and
8) effective monitoring of day-to-day operations.
2. As traffic volumes and complexity continue to increase, ATS supervisors, investigators of ATS
occurrences and safety managers will be required to learn more about the effects of such Human Factors on
the performance of ATS personnel.
— — — — — — — —
17-APP 2-1
Appendix 2 to Chapter 17
RISK ASSESSMENT OF ATS PROCEDURES
1. PURPOSE
1.1 The objective of assessing ATS procedures is to ensure that, as far as reasonably practicable,
potential hazards associated with the control of aircraft have been identified and actions to mitigate the
associated risks have been put in place.
1.2 This appendix provides general guidance on hazard identification and risk assessment processes
that are useful in the development or modification of ATS procedures.
2. HAZARD IDENTIFICATION (HAZid)
2.1 HAZid is a relatively thorough “top-down” technique that breaks down activities associated with the
implementation of ATS procedures into smaller components and identifies their potential failure modes and
their effect on ATS safety. Specifically, the HAZid technique is used to identify:
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