"To err is indeed human, so to err is normal" Human errors are usually pronounced in accident or incident reports. Seldom does one pay enough attention to these errors during daily normal operations as these either go unnoticed or unreported for whatsoever the reasons may be. Therefore, the causes of these errors and also the system threats prevalent in the daily operations may not be fully contained. On the other hand, problematic situations that are successfully tackled by human skills are quite often treated as less important than they really are. The job of an assistant controller (AC) is one of the important domains in air traffic management (ATM). The AC work together with air traffic controllers as team members and they do have direct and indirect contributions to the safe, orderly and efficient flow of air traffic. In this study, the threats, errors and potential undesired states occurring with AC during normal operations will be recorded by a methodology, which is new to Hong Kong Air Traffic Control (ATC). This methodology, called Normal Operations Safety Observation (NOSO), is built on the Threat and Error Management (TEM) framework. The results will generate a broad outline on what sorts of threats, errors and undesired states an AC can be facing during normal operations. The relative frequencies of occurrence of these conditions will be presented separately in tables and figures. The AC's potential vulnerabilities and capabilities to cope with these threats, errors and undesired states will be discussed together with a suggested ranking. It is envisaged that an analysis of the data collected will aid the development and evaluation of safety defence measures in ATM and further support the applicability of this data collection methodology in other ATM operations and subsequent researches. KEYWORDS:- Normal Operations Safety Observation, Threat and Error Management, Safety Management, Air Traffic Control

Yeung, Timothy Kwan Chi

English

Massey Research Online

Copyright is owned by the Author of the thesis.  Permission is given for a copy to be downloaded by an individual for the purpose of research and private study only.  The thesis may not be reproduced elsewhere without the permission of the Author.  Management of Threats and Errors in Normal Operations of Assistant Controllers A thesis presented in partial fulfillment of the requirements for the degree of Master m Aviation at Massey University, Palmerston North New Zealand Timothy Kwan Chi Yeung 2007 Abstract "To err is indeed human, so to err is normal. " Human errors are usually pronounced in accident or incident reports. Seldom does one pay enough attention to these errors during daily normal operations as these either go unnoticed or unreported for whatsoever the reasons may be. Therefore, the causes of these errors and also the system threats prevalent in the daily operations may not be fully contained. On the other hand, problematic situations that are successfu lly tackled by human skills are quite often treated as less important than they really are. The job of an assistant controller (AC) is one of the important domains in air traffic management (ATM). The AC work together with air traffic controllers as team members and they do have direct and indirect contributions to the safe, orderly and efficient flow of air traffic. In this study, the threats, errors and potential undesired states occurring with AC during normal operations wi ll be recorded by a methodology, which is new to Hong Kong Air Traffic Control (ATC). This methodology, called Normal Operations Safety Observation (NOSO), is built on the Threat and Error Management (TEM) framework. The results will generate a broad outline on what sorts of threats, errors and undesired states an AC can be facing during normal operations. The relative frequencies of occurrence of these conditions will be presented separately in tables and figures. The AC's potential vulnerabi liti es and capabilities to cope with these threats, errors and undesired states will be discussed together with a suggested ranking. It is envisaged that an ana lysis of the data collected wi ll aid the development and evaluation of safety defence measures in ATM and further support the applicability of this data collection methodology in other ATM operations and subsequent researches. KEYWORDS:- Normal Operations Safety Observation, Threat and Error Management, Safety Management, Air Traffic Control II Acknowledgements This research could not have been completed without the help and support of many people. It is a pleasure of mine to express my gratitude to the following:-Thesis Advisors Dr. Hans-Juergen Hoermann Senior Scientist Human Factors German Aerospace Center Institute of Aerospace Medicine Sportallce 54a 22335 Hamburg, Germany Germany +49-40-51309642 hans.hoermann@dlr.de Dr. Andrew Gilbey School of Aviation Massey University Turitea Campus Palmerston North New Zealand Professional Advisors Mr. Peter Pui Kong Leung Senior Operations Officer Civil Aviation Department Air Traffic Control Complex Hong Kong International Airport Hong Kong Mr. David Kwok Wai Cheung Senior Quality Assurance Manager Civil Aviation Department Air Traffic Control Complex Hong Kong International Airport Hong Kong Executive Vice-President Asia Pacific International Federation of Air Traffic Controllers' Associations I am obliged to the Hong Kong Civil Aviation Department for its support in granting me the approval to conduct this research in the Hong Kong Air Traffic Control Centre and for the approval of two-month's leave associated with data collection. I would also like to express my gratitude to Massey University and the Hong Kong Polytechnic University for their academic support. Most importantly, I wish to thank my family for Ill their patience with my four-year Master Degree studies. There are two gentlemen who are advocates of aviation in the Hong Kong Special Administrative Region and New Zealand respectively. They have put forward dedicated efforts in the establishment of this locally run Master Degree of Aviation course Their names, which should be remembered by all the students of this course, are as follows:-Professor Kee Ying Fung, Hong Kong Professor Graham J F Hunt, New Zealand Above all, my heartfelt thanks to those participating assistant controllers who have to remain anonymous for confidentiality. They allowed me to conduct the research while they were on their job. The success of this research relies heavily on their trust and participation. Without their kind assistance, there is no way that the research would yield a successful completion. "Thank you" The research undergoes an ethical consideration from Massey University that the research strictly follows the Code of Ethical Conduct for Research (Massey University, 2006). IV Table of Contents List of Figures................................................................................... ix List of Tables.................................................................................... x Chapter One: Introduction .................................................................... . The "Swiss Cheese" Model of Defences............................................ 2 ATM Vulnerabilities and Strengths................................................... 2 Line Operations Safety Audit (LOSA)................................................ 4 The Objectives........................................................................... 5 Chapter Two: Literature Review.............................................................. 6 Hun1an Errors............................................................................ 6 Human Performance Models.......................................................... 8 The Causes of Error Rule-based, Skill-based and Knowledge-based................................................................ 9 The "Wolf or Sheep" Violation.............................................. l 0 The Impact of Levels of Experience on Human Performance.................... l l Workload and Task Complexity....................................................... 11 Threat and Error Management (TEM) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12 Hypothetical Scenario........................................................... 13 Chapter Three: Method........................................................................ 16 Participants............................................................................... 16 The AC Sectors................................................................... 17 Materials................................................................................... 17 NOSO Observation Forms...................................................... 17 NOSO Codebook......................................................... 19 NOSO Database.......................................................... 22 Information Sheet and Consent Form................................. 22 Procedures............................................................................... 22 Stage One: Preparation............................................................ 22 Stage Two: Data Collection...................................................... 24 2-Week Review (for Stages One and Two).............................. 24 V Stage Three: Data Cleaning . . . . . . . . . . . . . .. . . . . . .. . . .. . . . .. . . . . . . . . . . . .. . . . .... .. 24 Stage Four: Data Analysis........................................................ 25 2-Week Review (for Stages Three and Four)......................... 25 Stage Five: Report Writing..................................................... 25 Stage Six: Presentation of Results.............................................. 26 Chapter Four: Results........................................................................... 27 NOSO Fact Sheet (l) General Overview.......................................... 27 NOSO Observation Forms...................................................... 27 Summary of Data Collected................................................... 27 NOSO Fact Sheet (2) Overview on Threats, Errors and Undesired States... 28 Overview on Threats............................................................ 28 Overview on Errors............................................................. 30 Overview on Undesired States................................................ 32 Overview on Threat and Error Countermeasures........................... 32 NOSO Fact Sheet (3) Explorations on Threats, Errors and Undesired States......................................................................... 33 Explorations on Threats......................................................... 33 Explorations on Errors.......................................................... 34 Explorations on Undesired States............................................. 37 NOSO Fact Sheet (4)- Relationship between AC Positions and Threats, Errors, Undesired States...................................................... 38 Relationship between AC Positions and Threats............................ 39 Relation between AC Positions and Errors................................... 40 Relationship between AC Positions and Undesired States................ 40 NOSO Fact Sheet (5) - Listing of Years of Experience in ATC/ AC and Number of Errors........................................................................ 41 Statistical Analysis (I) Years of Experience in ATC/ AC versus Number of Errors........................................................................ 42 Outlier............................................................................. 43 Spearman Rank Correlation Test on Experience of AC versus Errors............................................................................... 43 Two Groups of AC - Kai Tak and Chek Lap Kok........................... 44 Mann-Witney U-test on the Two Groups of AC............................. 44 VI Spearman Rank Correlation Test on Experience of AC versus Errors in the Two Groups of AC............................................... 45 Other Considerations........................................................... 45 Statistical Analysis (2) Years of Experience in ATC/AC versus Different Types of Errors............................................................... 46 Spearman Rank Correlation Test on Experience of AC versus Number of Different Types of Errors......................................... 47 Spearman Rank Correlation Test on Experience of AC versus Number of Different Types of Errors on the Two Groups of AC......... 47 Statistical Analysis (3) Relationship between Different Shifts/ AC Sectors and Number of Threats/Errors......................................................... 49 Relationship between Different AC Sectors and Threats.................. 50 Relationship between Different Shifts and Threats........................ 51 Relationship between Different AC Sectors and Errors...................... 51 Relationship between Different Shifts and Errors........................... 52 Summary of the Kruskal-Wallis Test.......................................... 52 Chapter Five: Discussion....................................................................... 53 Overview of Findings.................................................................. 53 Analysis of Findings ( l) in General................................................ 53 Analysis of Findings (2) in Details................................................. 54 Threats............................................................................ 54 Errors.............................................................................. 55 Relationship between Years of Experience and Errors..................... 55 Performance Markers........................................................... 56 Areas of Attention............................................................... 56 Events on Threat Management, Error Management and Undesired State Management................................................. 58 Threat Events............................................................ 58 Error Events.............................................................. 59 Undesired State Events................................................. 60 Limitations ofNOSO.................................... .. . . . . . . . . . . . . . . . . . . . . . . . . . .. . 60 NOSO in the Future.................................................................... 61 Summary................................................................................. 62 VII Chapter Six: Conclusion...................................................................... 64 Bibliography........................................................................................ 65 Appendix A 1 : NOSO Observation Form - Observation Demography................ 73 Appendix A2: NOSO Observation Form Handover and Takeover................... 74 Appendix A3 : NOSO Observation Form General Operations........................ 75 Appendix A4: NOSO Observation Form Threat Management........................ 76 Appendix A5: NOSO Observation Form - Error Management......................... 77 Appendix A6: NOSO Observation Form - Undesired State Management............ 78 Appendix A 7: NOSO Observation Form - Threat and Error Countermeasures...... 79 Appendix B 1 : NOSO Codebook - Threat................................................. 80 Appendix 82: NOSO Codebook Error................................................... 85 Appendix B3 : NOSO Codebook Undesired State...................................... 88 Appendix C 1 : NOSO Database Demography Worksheet.............................. 89 Appendix C2: NOSO Database Threat Management Worksheet..................... 90 Appendix C3 : NOSO Database Error Management Worksheet...................... 9 l Appendix C4 : NOSO Database Undesired State Management Worksheet......... 92 Appendix CS : NOSO Database Threat and Error Countermeasures Worksheet... 93 Appendix D : Information Sheet............................................................. 94 Appendix E : Consent Form.................................................................. 95 Appendix F : Abbreviations and Codes used in Threat Management, Error Management and Undesired State Management........................................... 96 Appendix G : Threat Management........................................................... 97 Appendix H : Error Management............................................................ 117 Appendix I : Undesired State Management................................................ 129 VIII List of Figures Figure 1.1 Reason's Swiss-cheese Model. ............................................... . Figure 1.2 Heinrich Pyramid ............................................................... . Figure 2.1 Three Levels of Human Performance ....................................... . Figure 2.2 Threat and Error Management Model. ...................................... . Figure 3.3 NOSO Coding System (Threat) ............................................. . Figure 3.4 NOSO Coding System (Error) ............................................... . Figure 3.5 NOSO Coding System (Undesired State) ..................... . Figure 4.1 Scatter Graph to show the Years of Experience in ATC with Number of Errors ....... . Figure 4.2 Scatter Graph to show the Years of Experience in AC with Number of Errors ............................................................... . Figure 4.3 Scatter Graphs to show the Years of Experience in ATC/AC with Number of Errors .............................................................. . IX 2 3 9 13 20 21 21 42 42 44 Table I Table 2 Table 3 Table 4 Table 5 Table 6 Table 7 Table 8 Table 9 Table 10 Table 11 Table 12 Tab le 13 Table 14 Table 15 Table 16 Table 17 Table 18 Table 19 Tab le 20 Tab le 2 1 Table 22 Table 23 Table 24 Table 25 Tab le 26 Table 27 List of Tables Observation Program ........................ ... ... ... ..... . ................. . Description of NOSO Observation Forms ............................ ..... . Performance Marker Scales .................. .... .. ... . . ..................... . Summary ofNOSO Data in the NOSO Observation Forms ... .. ...... . List of Threats recorded in NOSO .................. ........ .............. .. List of Errors recorded in NOSO .......... .. .............................. .. List of Undes ired States recorded in NOSO ......... .... ................. . Summary of T hreat and Error Countermeasures ......... ................. . List of Threat Category ..... .... ............................................ . Lin kage of Threats to Operations ........................... ...... ........ .. Linkage of Threats to Errors .................. .. ...... ..... .... .... ........ . Threat Management by AC ...... . .............. ....... .. ................... .. Category or Errors .......... . ..... .............. . .... . . . ..................... . Percentage of Intentional Non-compli ance in Different Categories or Errors ................ .. ............................ .. Linkage of Errors to Operations ........................................... .. Linkage of Errors to Threats .... .. .............. ............................. . Error Discovery by Personnel ... .. ............. .. . ... . ..................... . Outcome of Errors . . .. .... . .......... ............... . ........................ . Linkage or Undesired States to Threats/EITors .... .... ................... .. Undesired State Management .................................... . ......... .. Undesired State Discovery by Personne l ... . . . . . . . ................... . .... . Outcome of Undes ired States ... .. .............................. . ....... ... .. AC Positions versus Average Num ber of T hreats ................ . ...... . AC Positions versus Average Number of En-ors ........ .. ...... ... . ..... .. AC Positions and Shifts versus Occurrence of Undesired States ....... . Years of Experience in ATC/ AC versus Number of Errors ............. .. Ranks for Years of Experi ence in ATC/ AC and N umber of Different Types of EITors ....... ........ . ...................... . ........ ... .. . X 17 18 19 27 28 30 32 32 33 33 34 34 35 35 36 36 37 37 37 38 38 38 39 40 40 4 1 46 Table 28 Table 29 Table 30 Table 31 Table 32 Table 33 Table 34 Table 35 Correlation Matrix for Years or Experience in ATC/AC and Different Types or Errors ..................................... . 47 Ranks for Years of Experience in AC and Types or Errors (Chek Lap Kok Group) ...................................................... . 48 Ranks for Years of Experience in AC and Types of Errors (Kai Tak Group) .............................................. . 48 Correlation Matrix for Years of Experience in AC and Di ITerent Types of Errors for Kai Tak Group and Chek Lap Kok Group ....................................... . 49 AC Sectors versus Threats being converted into Ordinal Data Ranks ......................... . 50 Shifts versus Threats being converted into Ordinal Data Ranks........ 5 l AC Sectors versus Errors being converted into Ordinal Data Ranks... 51 Shifts versus Errors being converted into Ordinal Data Ranks......... 52 XI 

Management of threats and errors in normal operations of assistant controllers : a thesis presented in partial fulfilment of the requirements for the degree of Master in Aviation at Massey University

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Management of threats and errors in normal operations of assistant controllers : a thesis presented in partial fulfilment of the requirements for the degree of Master in Aviation at Massey University

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