NerlSafetyFinal by NATS

NERL Strategic Plan for Safety

2011-2015 April 2011

Contents

Section 1

Section 2

Section 3

The Way We Work

Raising Our Safety Capability

Reducing Our Risks

Strategic Vision SSE Classification Scheme NERL Safety Website Understanding Risk Safety Management System Front Line Engagement Safety Culture Professional Standards in Operations Lesson Learning Working with Others Improvement Areas

People & Human Performance Technology & Engineering Airspace & Procedures Managing Change Operational Risk Management

Infringements & Class G Operations Level Busts Civil Military Interactions Oceanic Operations Operational Interfaces

Glossary Foreword Strategic View Introduction

Glossary and Acronyms AC

Area Control

CFIT

Controlled Flight Into Terrain

ACAS

Airborne Collision Avoidance System

CP2

ACC

Area Control Centre

CP3

AENA

Aeropuertos Españoles y Navegación Aérea (Spain's ANSP)

CPD

Control Period 2 the 2nd regulatory period since PPP, ran from 2006 to 2011 Control Period 3 the 3rd regulatory period since PPP, runs from 2011 to 2015 Continious Professional Development

AMAN

Arrival Manager

DefCon

Defensive Controlling

ANSP

Air Navigation Service Provider

DMAN

Departures Manager

ATSA

Air Traffic Services Assistant

EASA

European Aviation Safety Agency

ATC

Air Traffic Control

EFD

Electronic Flight Data

ATCE

Air Traffic Control Engineer

ESE

Engineering Safety Events

ATCO

Air Traffic Control Officer

FAA

Federal Aviation Administration (USA)

ATIS

Automatic Terminal Information Service

FAB

Functional Airspace Block

ATM

Air Traffic Management

FISO

Flight Information Service Officers

ATSOCAS

Air Traffic Services Outside of Controlled Airspace

FMS

Flight Management System

BAT

Biometric Pressure Setting Advisory Tool

General Aviation

CAA

Civil Aviation Authority

Group Supervisor

CAIT

Controlled Airspace Infringement Tool (pronounced "Kate")

Human Factors

CAPC

Competency and Proficiency Co-ordinator

IAA

Irish Aviation Authority

CANSO

Civil Air Navigation Services Organisation

ICAO

International Civil Aviation Organisation

CAS

Controlled Airspace

iFACTS

Interim Future Area Control Tools Support

CBT

Computer Based Training

IFR

Instrument Flight Rules

iTEC

Interoperability Through European Collaboration

SCT

Safety Coordination Team

LAMP

LTC Airspace Management Programme

SESAR

Single European Sky ATM Research

LAS

Local Area Supervisor

SMF

Separation Monitoring Function

LHD

Long Height Deviation

SMS

Safety Management System

LHR

London Heathrow Airport

SOP

Standard Operating Procedure

LOA

Letter of Agreement

SPA

Safety Partnership Agreement

LOS

Loss of Separation

SSE

Safety Significant Event

LTIP

Long Term Investment Plan

STAR

Safety Tracking and Reporting System

LTMA

London Terminal Manoeuvring Area

STCA

Short Term Conflict Alert

MCRM

Multi Crew Resource Management

Terminal Control

MoD

Ministry of Defence

TCAS

Traffic Avoidance Collision System

MOP

Method of Operation

TLPD

Traffic Load Prediction Device

MSG

Management & Support Grade

TLS

Target Level of Safety

NEFAB

North European Functional Airspace Block

TMA

Terminal Movement Area

NERL

NATS Enroute Limited

TRUCE

Training in Unusual Circumstances and Emergencies

NSL

NATS Services Limited

UCE

Unit Competency Examiner

NUAC

Nordic Upper Airspace Control partners

VCCS

Voice Communications and Control System

OJTI

On the Job Training Instructor Prestwick Centre

Weighted SSE Index WS

An indexing system which allows direct comparison of SSE scores

PC PCG

Personal Contract Grade

WSM

Watch Safety Manager

PPP

Public Private Partnership

QNH

Altimeter sub-scale setting to obtain elevation when on the ground

Resolution Advisory

RAT

Risk Analysis Tool

Workstream

Foreword Safety is at the core of NERLâ&#x20AC;&#x2122;s business. We are proud to provide a service to our customers and a key element of this is protecting their safety in the air. Throughout CP2 we worked hard to improve our safety performance. We succeeded in almost halving our risk and reducing both the NATS and the non-NATS contribution to that risk. This was achieved by identifying the main causes of our SSEs and tackling them head on. In CP3, we have matured our safety strategy even further. We are still determined to reduce our SSEs, but we have also looked beyond our reported events to understand how our organisation can improve the underlying resilience of the air traffic system and of our own ways of working. This has led us to consider major projects such as a redesign of the terminal airspace around London and Manchester, implementing technology projects such as iFACTS to support our controllers in better operational planning, and far reaching reviews of recruitment and training to meet the changing needs of our future controllers. We are fundamentally overhauling our management of change and our operational risk management practices.

local actions to improve safety and their main strategic actions are reflected in this Strategic Plan for Safety. We have set ambitious targets for CP3. These are really challenging because the more that safety improves, the harder it becomes to make further gains. Yet, we know it is essential to deliver the best possible safety standards for our customers, many of whom are working with us to achieve improvement gains. I would like to take this opportunity to thank our customers for their continued energetic support in working together for safety improvement activities, despite the challenging economic times that we are all facing. I would also like to recognise the important contributions made by our partners in CANSO, the IAA and our Regulators in CAA and EASA for working with us to create a safer future.

I have become personally involved in our projects to address safety and as the Managing Director of the business this remains my top priority. Our Weighted SSE Index is not, and should not be the only measure of our success but it remains a useful indicator and we are always pleased when it shows some improvement. I have also invested time in coaching our key operational staff to become effective Watch Safety Managers because I passionately believe that the operational controllers must be the owners of our safety improvement activities. During CP3 I would like the emphasis to be on assisting the operational staff to define their own standards of safety and for the organisation to focus on meeting their priorities for improvement. The Units of course have their own Safety Plans; Swanwick and Prestwick Centres, Engineering and the College. These govern their

Ian Mills, MD NERL

Strategic View: Swanwick Centre

Strategic View: Prestwick Centre

This is an exciting time for Air Traffic Control. We have new technologies emerging that will both support and change the way that we operate, in ways that were intended by the design and probably in some ways not yet foreseen.

Now is the time when the Prestwick Centre is really getting into its stride. We have brought together different operations with people in new roles into a new Centre, created a Centre identity and implemented ground breaking new technology: all achieved safely. It has been an inspiring achievement by the Prestwick team.

Swanwick Centre employs some 800 operational controllers and handles around 2 million flights in a year. It is a hugely busy operation, and it has to continue seamlessly while we introduce new technology or special events like the Olympics. How will we make strides forward in our levels of service and safety? I would like to see:•

Our controllers and engineers helping to shape future evolutions of our technology, as they discover different and better ways to use it.

•

A more integrated approach as silos of expertise learn to create new solutions together.

•

Planning for flexibility as we recognise that during long projects the situation may change and our plans need to be revisited regularly.

Swanwick is a world class unit and I am looking forward to creating a bright future together with my team. Simon Hocquard, Operations Director (Swanwick)

A further 40% safety improvement in CP3 is a tough challenge. In my view it can only be achieved by step changes in our working methods, our technology and a focus and commitment from our teams to make those safety improvements. Where might we find such opportunities? Perhaps in:• • • • • •

•

True ownership of safety by our front line operational teams. A fresh look at assurance methods for our future needs. Flexibility and adaptability of our people. Collaborating with and learning from other companies at home and abroad. Managing change with all stakeholders on board, building on the past but not being constrained by it. Developing technology solutions and learning how to gain new safety benefits from the technology we already have. Improving our facilities to visualise new technology concepts and develop our ideas into usable tools.

Prestwick is a unique environment with an outstanding team and I know that we will rise to meet this challenge together. Pauline Lamb, Operations Director (Prestwick)

Introduction Traditionally safety has been improved by responding to serious incidents. Today, it is harder to learn from accidents and incidents because they are few in number and the system is complex. It has become less effective to improve safety by reacting to isolated safety events and a more proactive approach is needed. The goal must be a strong, systematic infrastructure that creates an inherently safe environment with multiple layers of defences to support a confident safety performance. It has become cliché to say that in safety critical industries over 90% of incidents and accidents result from human error, but it continues to be true. Human performance is both our greatest asset and our greatest risk. The majority of actions described in our safety improvement work streams are aimed at supporting human performance in some way, whether it is by improving safety culture and leadership, developing technology that helps controllers to plan and monitor, designing airspace that is less congested or easier to manage, implementing changes that meet expectations or creating operational structures and supervision that promote excellent controlling practices. Human performance is a very common causal factor in safety events but this does not mean that people are not professionally competent or are ‘doing something wrong’. It is simply a feature of normal human performance that occasionally humans do not perform quite as they intended. They may be faced with a situation that is new to them, be distracted or so focused on their primary task that something else is not noticed, they can mis-hear information or occasionally enter data incorrectly, whether they are an Air Traffic Controller, a Pilot or an Engineer. We need to be realistic. Our people are highly trained professionals dedicated to providing a good service, but a certain level of human variability and the occasional error is foreseeable. It is important that we design the system with that in mind. This means that we continuously improve the training, airspace and technology to

minimise the likelihood of errors, and to ensure that the situation is recognised and safely recovered when an error does happen. Therefore many of our safety actions are aimed at supporting excellent human performance and in parallel, providing safety nets to ensure that unsafe situations are never allowed to develop. In order to create a robust operation that is resilient to unexpected events and occasional variations in human performance, we must continuously improve the standards and systems within our operation and be vigilant to identify emerging risks. It is important to fortify the underlying safety health of the operation as well as treating incidents or ‘symptoms’ that arise. This Strategic Plan for Safety draws together the more strategic high level activities in the Swanwick Safety Plan, the Prestwick Safety Plan, the Engineering Assurance Strategy, the College Safety Plan, the Operational Evolution Plan and the Long Term Investment Plan including both Technology and Airspace developments, as well as actions specifically identified to address the safety improvement areas. The document is organised in three sections: The Way We Work: ongoing activities that are important to safety Raising our Capabilities: safety improvement projects to build our underlying resilience Addressing our Risks: safety improvement projects to focus on directly tackling the sources of our safety events

The Way We Work

Strategic Vision NATS is committed to being Proactive in Safety as one of our major brand values. “We work with the aviation industry to anticipate and manage risk before it impacts safe operations. We continuously develop our capability to set the standard in safety leadership.” Our strategic vision is designed to deliver a real improvement in safety for aircraft receiving a NERL service. Our strategic objective is to deliver a 40% reduction in the NERL Weighted SSE Index over CP3, an average of 10% each year. The target and upper limit is illustrated in Fig.1. The shaded areas before the “today” line represent our Weighted SSE Index performance since 2007. The shaded areas also indicate that some risks to our customers are attributable to NATS (or partly to NATS), but the majority of risks originate outside of NATS actions or direct responsibilities. NATS is committed to being proactive in safety, and so we actively pursue safety improvement for any risk that affects the safety of aircraft receiving our service, whether it is a NATS responsibility or not. Many of our activities to reduce risk involve working with others outside of NATS in order to address these risks, implementing safety nets or alerting services to allow our Air Traffic Controllers to alert pilots to possible errors, or sharing data with the industry that helps put additional information into the place where it can best improve safety, e.g. on web based facilities for pilots, or in the cockpit.

This strategic vision to reduce our weighted SSE index by 40% during CP3 will be achieved through our safety improvement areas. These will address the main risks to our operation including underlying causal factors (see Fig 6). ‘The Way We Work’ on safety is described In Section 1, then outlines two levels of safety improvement activities: 5 areas for Raising Our Capability and 5 areas for Reducing Risk. Raising Our Safety Capability (Section 2) actively promotes our general safety ‘health’. These capability improvement areas are not directed at solving specific incidents but at increasing the overall resilience and safety margins in our operation. These focus on developing Our People, Airspace Design, Technology, Managing Change and Operational Risk Management. Reducing Our Risks (Section 3) addresses the sources of specific safety event types apparent from our safety data. Five general types of occurrence account for approximately 90% of our weighted SSE index. These are Infringements, Level Busts, Civil-Military Interactions, Oceanic events and those arising from Operational Interfaces (including pilot-controller interactions, interfaces with Airports, adjacent sectors and other ANSPs). Many of these arise from causes outside of NATS. Our current safety performance (through CP2) is shown in Fig 7. A Strategic Objective in each improvement area identifies how we plan to address that particular aspect of safety. From this flows the individual Strategies – particular lines of work that we will undertake, and a table of high level activities that are planned. Below this there are a large number of individual actions that are not included in this document; they are maintained in the NERL Safety Website but are revised too frequently to detail here.

The Way We Work

Fig 1: Our Strategic Objective is to deliver a 40% reduction in the NERL Weighted SSE Index over CP3 (an average of 10% per year)

The Way We Work

NERL Safety Website

SSE Scheme Classification The SSE Scheme is used to categorise safety events and give some indication of their significance. The SSE scheme determines the severity category of incidents by identifying the level of control and the degree of separation involved. The level of control uses the ‘barrier’ model of safety: how many barriers were still in place to ensure the outcome was safe? If ATC resolved the situation effectively, then there is still potentially the opportunity for a last minute ATC intervention, for the pilot (or TCAS) to resolve the situation and finally ‘providence’, so the event would be classified SSE4. If all other barriers have failed and only ‘providence’ prevented the aircraft coming into close proximity, then that would be an SSE1.

The NERL Safety Website 2011 (Fig. 3) provides links to other relevant sites, material on safety improvement areas and other relevant activities.

The events are graded on a scale of 1 to 4 for severity (barriers) and A to D for the separation distance where 1A is the most significant. Different levels of SSE (1-4) are weighted and summed to create a Weighted SSE Index of events that occur in NATS airspace or where NATS is providing a service. This Index is a single measure plotted over time to produce a graph as shown in Fig 1 and shows separately events that are ‘NATS’ (i.e. wholly or partly attributed to NATS) or Non-NATS (where NATS had no involvement in causing the event). Standard Separation <=50%

>50% and <=66%

>66% and <100%

>=100%

Providence

SSE1a

SSE1b

SSE1c

SSE1d

Pilot

SSE2a

SSE2b

SSE2c

SSE2d

ATC but not effectively

SSE3a

SSE3b

SSE3c

SSE3d

ATC

SSE4a

SSE4b

SSE4c

SSE4d

Level of Control

Fig. 2: SSE Classification Scheme

Fig. 3: NERL Safety Website (See Http://natsnet/nerlsafety)

The Way We Work

Understanding Risk Understanding risk is particularly important to assure safety and understand where to target our actions. NATS operates a Safety Significant Events (SSE) scheme and an open reporting system for Observations, which are held in our Safety Tracking and Reporting (STAR) database. Our Weighted SSE Index is an internal measure of safety performance based on our scheme. Understanding our risk is crucial to the effective development and implementation of this safety plan; both in being confident that we are addressing our key risks and also in monitoring and refining how well we are tackling them. The key to this is through effective measurement of risk performance and in identifying and tracking a wider view of risk. The Weighted SSE Index is a convenient way to express risk as a single value, but we recognise its limitations. Risk has many facets and it is a challenge to depict it in a way that is simple but comprehensive, holistic yet doesn’t dilute hotspots. We are continually working to improve our understanding of risk. The first core activity to support this is the development of a Consolidated Risk Picture to enable the various different facets of risk including both leading and lagging indicators (see Fig 4) to be visualised and tracked in the context to which they apply. This Consolidated Risk Picture is being developed to address the needs of management and operational staff across the organisation and is closely linked to international projects to improve the way the aviation community measures and represents risk. Measuring the safety qualities of the Operations Room at any given time is both the most difficult and most important task in gathering leading safety information and this will be evolving during the months and years ahead. It is based on a model of balancing operational Demand (e.g. traffic complexity, special events, weather) with Capability (e.g. training, staffing levels, support equipment) as measured by workload ratings, ‘day to day’ observations, audits and operational measures yet to be developed.

While capability matches demand, the system is ‘in balance’ and the safety of the operation is protected; if demand begins to outstrip capability, then human operators can become stretched and safety performance may suffer. If capability significantly exceeds demand, then we may not be giving our customers best value for money. This means it is important to be able to monitor and respond to both Demand and Capability. In practical terms this is already managed in the Operations Room but we are working to improve our capability to support these decisions with better data. The second core activity is in the creation of a common framework for the classification of risk associated with incidents and events. This work is focused, at this stage, primarily with the wider international aviation community, but the decision to trial the European RAT is a key step for NATS (The use of the RAT by European ANSPs will be measured as an European safety performance indicator from January 2012). The intention is that this activity will facilitate the development of a single Risk Performance Metric that can be used to measure the risk associated with a very wide range of events within the airspace system. For NATS it will enable a wider range of data to be used to enhance our knowledge of risk performance beyond the SSEs metrics we use at present. Ultimately data from a wide range of sources and different levels will be used. Some of these data will be weighted and represented geographically in a tool which is being developed, known as ‘Touchstone’ (see Fig 5). This takes account of incidents, SSEs and Airprox at the highest level, supplemented by data sources such as TCAS, STCA and STAR and supported by information from the operational context that helps us to assess the safety performance of the Operation on an ongoing basis.

The Way We Work

Fig 4: The data ‘iceberg’. This includes examples of sources of data at various levels, ranging from incidents that have occurred to data that may have relevance to the likelihood of future events such as traffic complexity and the frequency of safety prevention behaviours actually occurring in the operation.

Fig. 5: Touchstone: typical output from the tool showing short term conflict alerts, including the higher severity ‘red alerts’ (in red) and the lower severity ‘white alerts’ (in grey).

The Way We Work

Most Common Causal / Aggravating Factors 2010 Non standard phraseology Insufficient decision / plan Controller/Pilot under training Conflict outside of controlled airspace Altimeter setting error Mis-perceive visual information Forget planned action Responded to TCAS/GPWS Military Controlled Aircraft Failure to follow ATC procedure Distraction - job related Inaccurate/no recall from w orking memory Correct pilot readback follow ed by incorrect action Incorrect decision / plan Not see Civil uncontrolled aircraft Unauthorised entry into regulated airspace

No of SSE 1-4 a/b

Fig 6: Our Safety Improvement Areas will address key causal factors

The Way We Work

120 113

100 91

85 80 75 Number of Events

67 61 60 51

26 24 20

NATS/Dual

Non-NATS

NATS/Dual

2006

Non-NATS

NATS/Dual

2007

Non-NATS

NATS/Dual

2008

Non-NATS

NATS/Dual

2009

Non-NATS 2010

Total SSE1-4a/b

113

SSE4a/b

75 57

SSE3a/b

SSE2a/b

SSE1a/b

Fig 7: NERL SSE1-4 a/b events by attribution Percentage reduction from 2006 to 2010: NATS / Dual 64% Non-NATS 34%

The Way We Work

Safety Management System The Safety Management System is the basic means by which NATS manages safety. It describes the structure and elements of the process that keeps safety alive and current within the organisation. At the heart of the SMS is the NATS Safety Policy. This sets out what we are committed to achieve in terms of safety performance and how we will deliver it. The Safety Policy guides and directs the management of safety within NATS; from how the business operates safely today, through to the planned safety improvements for the future captured in our Strategic Plans for Safety. Through the promotion and application of the Policy, we ensure that we have the necessary organisation, culture, awareness, communication, capabilities and behaviours to ensure that appropriate safety objectives are set, monitored and achieved. Our Safety Policy is delivered through the application of our SMS which operates a continuous cycle (see Fig 8) of monitoring performance to understand our safety risks, improving safety where risks are identified, controlling the implementation of change, and actively managing operational risk during service delivery. These processes inform, and are informed by, our organisational culture and policies. All of our activities are set in a context of working with others and we work with our customers, regulators and other ANSPs whenever we can.

Fig 8: The NATS Safety Management System â&#x20AC;&#x2DC;Wheelâ&#x20AC;&#x2122;

The Way We Work

Front Line Engagement Operational safety occurs in the front line operation and the interaction between Air Traffic Controllers and the Pilots receiving their service. All too often, in safety critical industries such as ATC the ‘safety’ activity occurs far from the Operation, in documents and action plans that are remote or possibly not recognisable to the people doing the job where safety resides. It can be a difficult balance, because operational staff are typically busy with the task at hand and may have little time to participate in additional projects for strategic improvements in safety. However, safety that is detached from the operation is clearly not the best answer and the risks perceived by front line staff and their preferred solutions must clearly play a leading role in any safety improvement programme. It is also crucial that operational staff feel ownership of the safety of their service and do not regard safety as something that happens ‘somewhere else’. There are positive efforts to ensure that front line staff become more engaged in sustaining and improving safety in the operation. At the Swanwick Centre, WSMs have been appointed and received a program of personal coaching from the Managing Director and Safety Director. The WSMs have formulated the Swanwick Safety Plan based upon their view of the important risks and best solutions to address them. At the Prestwick Centre operational ATC safety improvements are identified by, and delivered through, the SCT and the watch safety structure. The SCT is led by a Relief Operations Supervisor and includes three operational ATCOs with input from the operation. The majority of work streams described in this document have leaders that reside in the operational ATC centres rather than the CTC and all work streams are positively engaged with the relevant operational teams.

The Way We Work

Safety Culture Aviation is one of the most highly regulated industries in the world. ATCOs, pilots, radar engineers, aircraft engineers, and other key personnel are selected, trained and examined to pretty much the same standard worldwide. Airlines fly similar aircraft under similar operating conditions globally. So why is it that, depending where you are in the world, you are up to 42 times more likely to die in an aircraft accident than you are in other places (Reason, 1997 Managing The Risks of Organizational Accidents, Ashgate Publishing, Farnham, UK) Evidence from accident investigations and pathological analysis of safety system failures points to Safety Culture as a key element. Safety Culture issues were identified as the key factor which caused the deaths of people in the Space Shuttle, Herald of Free Enterprise, Überlingen, King's Cross, and Nimrod disasters, respectively. That is why it is important to understand what our Safety Culture looks like - and how we can improve it. Leadership plays a vital part in setting the right Safety Culture in an organisation. Managers need to demonstrate that- when it comes to safety- what they do is consistent both with what they say and with what they think. But leadership alone won't change Safety Culture for the better. We all - regardless of whether you're an ATCO, ATSA, ATCE, MSG, PCG, or STAR - need to demonstrate that the way we think about safety is reflected in the way we talk about safety and, ultimately, is demonstrated in the way we behave when it comes to safety. In order for this to happen, NATS constantly engages people in the key elements of a successful Safety Culture. Our activities involving Safety Culture improvement are embedded within our safety improvement work streams including ‘Operational Risk Management’, Managing Change, Technology & Engineering and ‘People & Human Performance’.

the door at the college. We will develop specific training modules targeted at operational staff throughout their careers – from college, to unit training, and beyond. Further modules will focus on Safety Culture in leadership roles, such as LASs and UCEs. The safety capability of our operation will be measured, understood, and improved through the development of a Safety Capability Model aligned with similar activities in NSL. Furthermore, workshops for safety leaders will ensure that we constantly evolve and improve our Safety Culture and our Safety Capabilities in all roles, whether operational or non-operational. The success of these activities will be measured through direct interaction with people throughout the organisation, through the Safety Capability Matrix, Safety Culture focus groups, Safety dip tests, and operational Safety Days.

Professional Standards in Operations ATC is a professional role in a safety critical environment. The consequences of inappropriate action are potentially catastrophic, so we pay close attention to professional standards in our operations. We will offer guidelines and training to support the practice of Just Culture and help determine acceptable behaviours. Conformance to correct ATC procedures is essential and this will be the subject of some careful audit and checking this year to revisit procedures and understand why non conformance may occur. During CP3, there will be positive movement to raise professional standards in the operations room and address the causes of procedural non-conformance. To support this, operational staff are developing measures of our capability for key aspects of their performance e.g. procedural conformance and change management. This will be used to measure progress towards continuous improvement of professional standards in our operation.

These work streams will shape the way we think, talk, and act about Safety Culture from the first day a controller walks through

The Way We Work

Lesson Learning The ability to learn lessons is an essential ingredient for strengthening our safety resilience. Good reporting rates have led to NATS having a healthy set of potential safety lessons from which to learn (e.g. by improving procedures or making event replays available for controllers to view in safety kiosks). However, as a proactive organisation we don’t want to rely solely on incident data to help us learn and improve. Increasingly we recognise the importance of identifying risks and implementing best practice before an incident occurs. To this end, we will consult both internally and externally to gather and prioritise the key lessons to be learned from our own and other industries. Operational staff, UCEs, and supervisors, our Eurocontrol, CANSO and airline partners, and industries beyond aviation all have information and experience from which we can learn and help protect ourselves. In order to facilitate this, a new Safety Management Manual procedure is being developed detailing a NATS-wide framework for making local unit safety learning more robust and effective.

Working with Others In a complex international industry such as aviation, much more is achieved by working with others than working in isolation. Many of the risks to aircraft receiving our service originate outside of NATS and so it is essential to work with others to address those issues effectively. Both within our Safety Improvement areas and in NATS wider activities, we are proud to work with our partners; some of our key activities are working with:CANSO to improve the measurement and prediction of ATM risk and drive risk reduction at a global level. Together we have agreed to:• Develop a plan for improving Runway Safety in collaboration with Airservices Australia and other CANSO participants.

•

Work with the FAA and Airservices Australia to develop the Safety Management System of the future. Our Regulators to ensure that new regulation enables a sensible and pragmatic approach is taken by UK Air Traffic Providers to:• Establish a common interest framework where we can collaborate and support each other on European regulation issues. EASA and the European Commission to assist in development of a European ATM safety regulatory framework that supports the delivery of operational safety improvements to:• Establish an informal partnership with EASA to help steer the rulemaking process and regulations. The SESAR programme to efficiently deliver safety benefits and:• Play a leading role in the trial of the Eurocontrol Accident Incident Model to ensure that it is transformed from a theoretical concept in to a practical tool. The SPA to create a safer future in partnership with our customers:• Develop a joint safety plan with the SPA airlines to focus on common risk areas. The IAA and our customers to improve safety through the UKIreland Functional Airspace Block:• Explore the feasibility of a common approach to SMS e.g. convergence with UK-Ireland, the NEFAB and the NUAC partners; • Develop a common UK-Ireland FAB SMS; • Ensure that a process for application of SMS principles in joint FAB projects is developed. Working with others on safety issues happens at many levels in the organisation including the External Safety Team in the Division of Safety, Development and Investment and at local level on the units, for example PC working with AENA and Madrid Centre on Oceanic safety, and at Swanwick with Brest ACC and Maastricht to explore safety at sector interface level (see Operational Interfaces on page 40).

The Way We Work

Improvement Areas How Improvement Areas Support the Strategic Vision Strategic Vision

To deliver a 40% reduction in the NERL Weighted SSE Index over CP3, (an average of 10% per year)

Safety Improvement Areas

Our 10 safety improvement areas will improve safety performance to achieve the Strategic Vision. 5 are Capability Enhancements (Our People, Airspace Design, Technology, Managing Change and Operational Risk Management) that increase the general safety health of the organisation. 5 are Risk Reductions (Infringements, Level Busts, Civil Military interactions, Operational Interfaces and Oceanic Airspace) that specifically address the top 5 event types, covering 90% of risk in the weighted SSE index

Strategic Objectives

A statement in each safety improvement area that explains the fundamental strategy to achieve the improvement

Strategies

Lines of activity that will give some practical direction to how the Strategic Objectives will be achieved

Actions

A table of high level actions that commit to the specific activity and timeframe to achieve the Strategies

Action Logs

A detailed list of actions that support the actions above, they are maintained on the NERL Safety Website but are not included in this document as they are reviewed and revised continuously

Targets

The tangible difference that each Safety Improvement area hopes to make, some within FY 11/12, some within CP3 or annually throughout CP3

Examples

Each Risk Reduction includes an example of a safety event in that area

Raising Our Safety Capabilities

Raising Our Safety Capabilities 20

Raising Our Safety Capabilities People and Human Performance The Issue The human is and will remain pivotal to the safe and efficient operation of NATS airspace. Over the next few years, the role of the human in ATM will change with the introduction of increasingly sophisticated support tools; new airspace designs and the return of traffic levels. These changes will place new demands upon the controllers of the future. Acceptable levels of human capability will not emerge by chance. Strategic Objectives To provide a foundation of human capability such that future changes are inherently low risk. We will achieve this through selecting and training the right people to do the operational jobs of the future; providing new ATM technology that is safe and fit for purpose; understanding and managing causes of workload within the operation and monitoring safe controlling behaviour.

Provide operational staff with the right tools: Provide equipment, airspace and procedures that support human abilities and avoids traps for human vulnerabilities. Proactively design safety risks out of the ATM system. Make sure that equipment, airspace and procedures are fit for purpose and that the user will be able and confident to use them before they go into service. Manage operational workload: Create and validate a method which accurately predicts the workload impact of changing traffic patterns and use this to avoid overloads (and under-loads) during operational periods. Understand performance levels: Collect, analyse and present data on human performance that is meaningful to operational staff and is timely. Provide information on which techniques or circumstances have produced the best safety results in the past. Provide a means for practicing infrequently used skills, advanced or unusual skills. Obtain information to monitor the level of human performance risk within the organisation, feed this back to operational staff and plan action when necessary. During CP3 we aim to:•

Strategies Select & Train people to do operational jobs: Understand the operational roles within the organisation (now and in the future) and the competencies that are demanded. Select people who demonstrate these competencies or can acquire them. Provide the training to develop the necessary skills and knowledge. Make sure accountabilities are clear and that people have the right training to discharge them.

• • •

Diminish the frequency with which controllers report high workload because the factors contributing to high workload are known and managed. Produce a demonstrator of the changing role of the controller sufficiently in advance that it enables equipment and training. decisions to be made and validated for key operational changes Show that Day to Day (and Safety in the Wild) measurements indicate increasing use of protective behaviours in operational controllers over CP3. Reduce the number of incidents with an HP related causal factor.

Raising Our Safety Capabilities Risk Factor

Action

Owner

Date

Select & train people

Describe and make explicit the changing role of the controller over the course of the LTIP and due to technological change such as iTEC and use this to create training and selection policy, and publish in a useable format

Human Factors

Oct 2012

Select & train people

Publish a plan to evolve training to a seamless continuum through college, unit, OJTI and in service training (e.g. TRUCE) and thus improve training effectiveness

Human Factors

Mar 2012

Select & train people

Develop a training module for initial controller training to address skills related to infringements, planning and â&#x20AC;&#x2DC;not seeâ&#x20AC;&#x2122; (e.g. visual scanning)

Human Factors

Mar 2012

Provide the right tools

Provide specialist HF support to technology & airspace design projects to ensure effective human machine interfaces are consistently delivered to the operation for (dates subject to project progress)

Human Factors

a) b) c) d)

Mar 2013 Apr 2014 Apr 2012 Dec 2014

Human Factors

a) b) c) d)

Mar 2013 Apr 2014 Apr 2012 Dec 2014

e.g. a) ITEC Provide the right tools

b) EFD for TC

c) Olympics and

d) LAMP

Ensure that sources of Human Error are systematically identified and mitigated before changes are introduced to the operation for major projects (dates subject to project progress) e.g. a) ITEC

b) EFD for TC

c) Olympics and

d) LAMP

Provide the right tools

Quarterly review of STAR data and analysis of incident and performance data to understand the key areas where technical improvement would reduce the likelihood of human error and use this to brief programmes and Units

Human Factors

Quarterly from Jun 2011

Manage workload

Use workload measurement technology and workshops to a) understand workload patterns within the operation and the factors influencing workload, b) create and implement improvement plans and c) monitor progress against plans to support 10% improvement target, and adjust plans accordingly

Human Factors

a) Oct 2011 b) Mar 2012 c) Mar 2013

Manage workload

Conduct studies to correlate workload data with other data sources so that the predictive capability of the operation is improved and recommend actions e.g. improvements to TLPD technology or use in the operation

Human Factors

Jun 2012

Understand Performance Levels

Collect focused Day to day (and Safety in the Wild) measures pre and post critical change to understand the impact of changes within the operation e.g. a) EFD for TC b) Olympics and c) LAMP

Human Factors

a) Apr 2014 b) Apr 2012 c) Apr 2015

Raising Our Safety Capabilities Technology & Engineering The Issue ATC today relies extensively upon the human controller and technology is being introduced to increase the opportunity for advance planning and reduce the amount of tactical intervention required, to alert pilots and controllers to the possibility of incorrect situations and to improve sequencing and traffic management. As use of technology increases, so does reliance on engineers. Engineering has invested greatly in recent years to improve its resilience, processes, systems and safety culture and the strategies below aim to build on that, targeting both technical and human capabilities with an overall theme of embedding a strong positive ownership of safety into every individual.

Strategic Objectives To support operational human performance through technology, and to support that technology with engineers who are acutely aware of the safety consequences of their work and prepare themselves and their workplace accordingly.

Strategies New Technology: Through our LTIP we will develop, implement and maintain cutting edge new technology systems to support our Air Traffic Controllers to improve information available, support monitoring planning and alerting, and provide safety nets to reduce any vulnerability to human error. System Design: Learn from existing systems and use current best practice to ensure that future systems are more robust, error resistant and reliable and do not exhibit the (often low level but common) issues sometimes experienced in today’s systems. Risk awareness and management: There will be a scheme to better measure the safety impact from engineering events, identify mitigations and support staff in managing the risks. This helps sustain a balance between common low risk and rare high consequence events.

Complete assurance: Our Quality Management system embeds Process Improvement in the culture and methodologies of engineering, with improved auditing and monitoring, KPIs and statistics to identify opportunities for improvement. Human performance: Engineering systems are extremely resilient such that many failures are now as a result of human intervention. Improved measurement of human performance related causal factors will be introduced. Competency: Our training is timely and at the right level thereby ensuring staff are both confident and competent. Ongoing training, including system exposure and TRUCE will be scheduled into operational rosters. Improved Operational Service Management: By incorporating skilled engineering managers into the ATC operations rooms we have a clear picture of the ATC tactical requirements allowing engineering to respond much better to service delivery issues. Good practice and lesson learning: An improved lessons and good practices sharing method will allow our staff to easily gain from the experiences of others, thus reducing the number of unwanted events from known causes. Safety Culture: Our ongoing programme of safety culture and awareness activities allows our engineers positive ownership of safety. The programme will include operational safety training, risk awareness workshops, safety training, open reporting and feedback mechanisms and detailed safety responsibility statements which have been agreed to by all staff. During CP3 we aim to • Meet LTIP targets and timescales for iFACTS, EFD, Datalink and AMAN / DMAN. • Measure Risk through the new Engineering SSE Scheme and show a notable reduction year on year. • Improve Engineers’ safety awareness as measured through dip tests and causal factors

Raising Our Safety Capabilities Risk Factor

Action

Owner

Date

ATCO workload, perception error, need for tactical intervention

Safely implement iFACTS in AC to provide trajectories and visualisation to support earlier planning decisions and reduce need for tactical intervention Implement EFD (Electronic Flight Data) in PC and TC including an automatic check of Cleared Flight Level vs Selected Flight Level

Projects

Oct 2011

Projects

Implement Datalink automated clearances

Projects

Jan 2011 (PC) Mar 2014 (TC) May 2014

Implement upgrades to AMAN and DMAN to provide useful, useable tools Implement Catch Up warning tool to a) reduce loss of separation at LHR and develop it to b) reduce wake turbulence risks at LHR Improve reliability and robustness of VCCS and reduce call blocking Introduce new Engineering Safety Event measurement system and influence development of RAT to mutually acceptable solution. Improve identification of causal factors in engineering incidents Provide Operational Risk and Safety training and exposure for all staff through workshops, shadowing, TRUCE and CBT Carry out a review of operational engineering Risk management

Projects

Apr 2013

Projects

May 2012

Engineering WS Lead

Dec 2012 Oct 2011

WS Lead

Mar 2011

WS Lead

Oct 2012

Develop a method of self managed continuous assurance for Engineering

WS Lead

Oct 2011

Carry out Human Factors audits of key Engineering Service Delivery systems, sites, control rooms etc, and make improvements where identified Develop a tool that will provide a realistic assessment of the safety and business impact of any system outage Review all Safety Accountabilities and Responsibilities and ensure all staff understand them Create a more effective method of identifying and disseminating good practices and lessons learnt Identify root causes of system reliability and error resistance issues to ensure future system designs do not have similar problems

WS Lead

Mar 2012

WS Lead

Dec 2012

WS Lead

Oct 2011

WS Lead

Mar 2012

WS Lead

Mar 2012

Future automation opportunities do not have required electronic data Radio communication error prone and frequencies congested Arrival and departure congestion Wake turbulence on approach Communications / Radio Reliability Safety impact of Engineering events not consistently measured Staff may not understand the reality of how they can impact the ATM operation Unsafe situations due staff/ systems not adequately prepared Audits sometimes identify areas for improvement which should have been previously clear to staff Evidence suggests that engineering incidents have been caused by poor human factors design The impact of removing one or more services from ATC is not always clear Staff are not always clear about their responsibilities for safety We do not always learn from the issues experienced by ourselves or others Reliability issues in current systems should not occur in future systems

Raising Our Safety Capabilities Airspace & Procedures The Issue Airspace design can make a significant contribution to improving safety performance. There are a number of competing demands and constraints to manage as part of this process, especially in the South East of England. Nevertheless, the level of safety risk can be reduced by application of best practice design principles, either by resolving intrinsic issues such conflicting traffic flows or high workload for Air Traffic Controllers, or by creating a managed environment where pilots are less likely to make an error, or if errors occur, are more easily recovered. Strategic Objective To create a step-change in NERL’s capability such that new airspace designs are inherently low risk. We will achieve this through the reduction of conflicting traffic streams, increased systemisation and a reduction in the likelihood of human error on the ground and in the Flight Deck, with a key focus being the terminal airspace environment. Strategies

London and Manchester TMAs are redesigned in order to modernise our airspace structures. UK High Level Sectors are developed to accommodate flexible routeing strategies and align with neighbouring Air Traffic Service Providers. Queue management techniques are developed and airspace related tools-based developments. A ‘total system’ approach is taken when considering the integration of new airspace and technology developments. A higher common UK-wide Transition Altitude is introduced as an enabler for more systemised and environmentally friendly controlling methods in Terminal Airspace. Optimal design principles are applied to all new airspace designs to (as documented in ‘Safety By Design’). During CP3 we aim to:• •

Deliver Airspace change according to LTIP delivery schedule. Reduce our vulnerability to human error risks through better airspace design.

Airspace change requests receive a timely response to from our Operational Units or other airspace users / stakeholders. Air Traffic Controllers are actively engaged to identify and prioritise areas of risk and possibilities for improvement (e.g. Willo and Heathrow Approach). ‘Airspace safety audits’ are periodically conducted to ensure that our airspace infrastructure and procedures remain fit for purpose in the context of an evolving operational environment. The Future Airspace Strategy Implementation Programme is developed with the Directorate of Airspace Policy and supports NERL Development & Investment in matters of airspace policy. 25

Raising Our Safety Capabilities Risk Factor

Action

Owner

Date

Traffic too dense or highly tactical (e.g. conflicting flows or a lack of flexibility for mix of traffic types) Traffic too dense or highly tactical (e.g. conflicting flows or a lack of flexibility for mix of traffic types) Complex departure/arrivals & interactions (e.g. step climbs) vulnerable to human error Infringements / traffic growth; vulnerability to human error; incompatibility with adjacent sectors Unpredictable and bunched arrival sequence Unpredictable and bunched arrival sequence

Redesign London TMA â&#x20AC;&#x201C; Commence Changes

Programmes / Swanwick

Dec 2015

Redesign Manchester TMA â&#x20AC;&#x201C; Commence Changes

Programmes / Prestwick

Dec 2014

Raise the Transition Altitude

Programmes / D&I

Dec 2013

Commence Airspace Safety Audits within the Operation

Swanwick / Prestwick / DoS

Mar 2012

Develop queue management concepts

Swanwick / D&I / Programmes UK Irish FAB / D&I / Programmes

TBC

FAB High Level Sector Development

May 2013

Raising Our Safety Capabilities Managing Change

Develop People: who are ready, willing and able to play their part in bold changes.

The Issue Throughout CP3, NERL will introduce ambitious and ground changes in a very complex environment, such as iFACTS, EFD and, of course the Olympics in 2012. Today, the issue is that we deliver change which fails to meet the intended benefits satisfy user expectations due to: • • •

breaking and ITEC too often and / or

Incomplete understanding of the requirement early in development, leading to late change proposals to ensure the solution is operationally fit for purpose in the eyes of the user. Poor engagement and ownership of the operational workforce leading to difficulties in acceptance of change, training and workforce confidence in the final solution. Unexpected changes to methods of operation required due to poor definition of the operational requirement and misunderstanding of the operational environment.

Strategic Objectives The strategic objective is to transform our approach to managing change such that operational capabilities and solutions are defined, developed, driven and embraced in partnership with the operational community, and that our processes provide the framework to ensure we do the right things, at the right time, with the right people consistently so that the “issue” is completely mitigated.

Strategies Create an organization: where our roles are optimized for managing change, and we all understand the part we play. Apply Excellent Governance: the right capabilities for reviewers/Project Board Chairs; good questions as part of the review with an emphasis on defining and delivering benefits; outcome is rigorous, consistent and an informed process which provides focus and improved capability.

Apply Skilled Evaluation: a Test Team a cross functional trained core team; building a capability in Operational Development and Evaluation; Special training in developing, evaluating and validating systems and airspace changes; Increase capability and ensure user ownership of change Ensure a consistent approach: to the critical communications thread throughout the change process. Create processes: that ensure we are defining, developing and transitioning the changes we need, including: Change Management process: Front end engagement of operations, focus on early simulations and trade offs. Use a Total System Approach, i.e. a process that for any change, airspace, procedures, the cockpit, operational context and equipment are all considered in reaching the solution to be delivered. Clear Purpose of Change: continuing dialogue between operational centres and the Strategy and Investment Team to ensure alignment with strategic direction, correct prioritisation, and understanding of the need and context for change. Ensure there is a clear expectation through CP3 and beyond and that Operational Teams are able to provide accurate context and reasoning for changes. User Centred Design process: real focus on what makes a good design/requirement/meets operational need. Outcome will maximise capability through proposed technical and operational change. During CP3 we aim to:Ensure that key activities are in action to support to iTEC, developing capabilities for operations staff involved in projects, and User Centred Design. Target is to have a robust roadmap by end March 2011 and to define and monitor progress against this.

Raising Our Safety Capabilities Risk Factor

Action

Owner

Date

Poor requirements definition leading to lack of user acceptance and ownership later in the project. Lack of focus on definition and delivery of benefits. Lack of early prototyping and inconsistent input from user leading to possible incorrect solution and acceptance criteria Inconsistent application of and/or weak governance

Training programme for Operational Test Users will be established at the units with the objective of providing the skills to operational staff to integrate into and influence projects at an early stage.

WS Lead

Nov 11

WS Lead

Nov 11

WS Lead

Nov 11

WS Lead

Nov 11

WS Lead

Nov 11

Poor communication with the user communities which affects buy in. Project Plans do not adequately recognise what operational inputs are required. Desire to meet board milestones at any cost affects quality.

New Validation and User Interface procedures and training is being developed and are being introduced and 'prototyped' in the iTEC Programme Project Management Capability Roadmap assessments have been refreshed and re-launched to ensure continued compliance with Level 4 of the Roadmap Core Teams are being introduced at the Units who will be familiar with the Operational Evolution Plan and LTIP programme and will have responsibility for ensuring unit staff remain briefed on change. Assessment is underway to establish some metrics on these

Raising Our Capability Operational Risk Management The Issue Safety in NATS is delivered by operational controllers tactically controlling aircraft, supported by supervisors and network managers managing traffic flows. The environment of the Operations Room is focused and dynamic, responsive to the demands of traffic peaks and troughs. It embodies the typical issues inherent in an industry that relies heavily on human performance and skill: effective supervision, workload management, sustaining skills and competence, rostering and seamless handovers and the management of alertness and fatigue. All of these need to be successful to achieve safety at the point of delivery. It is very difficult to effect change at the sector and supervisory level within the operation. Yet this is the most important level to influence and change because it can have the most significant benefit on the overall system safety.

direct effect on the safety of the operation within the organisation, the way the organisation understands and acts upon risk and the organisational culture itself. CP3 is a challenging period of change, including the Olympics, forecast regeneration of traffic and enormous technology change. These circumstances have the potential to negatively impact safety as controllers adjust and adapt to complex new situations. It is at such times that operational safety behaviours are crucial and we know that safety behaviours are influenced by the supervisory staff and first level management. This work stream aims to mitigate the potential negative impact of the forthcoming changes by excellent management in the Operations Room and ensuring maintenance of the safety behaviours that we need. Strategic Objectives To change the way that the organisation ‘thinks’ about safety such that safety is an integral part of the organisation at all levels. We will consider the safety problem in two dimensions:-

Delivery of safe operations traditionally includes learning from safety related events, and adapting the operational environment to address the risk identified. As systems become safer, there are less safety events to learn from, so this method of safety improvement becomes less effective as the model of risk changes.

Preventative Safety:-

To sustain and improve safety performance, alternative methods need to be employed, specifically to recognise what we do well, and make this the norm, and thus provide the platform for progressive change. At the operational level, system safety is enhanced by improving resilience by developing the skill and competence levels of all of those engaged in the delivery of ATM.

Managing risk in the operation:-

A wider purview of safety will embrace the organisational structure, supervision and professional (skill) development of all who have a

•

Improving our ability to detect and safely recover a dynamic situation when something starts to go wrong during operational controlling.

Adopting techniques that manage the day to day interactions of traffic in the operational environment at the supervisory and the sector level as well as the macro level, and reducing Non Conformance. Creating an operational staff structure that optimises the ability to manage the day to day operation safely.

Raising Our Capability Strategies Develop continuous professional training within the ATM operational environment and eventually for all roles within NATS – giving a practical opportunity to develop new ways of performing each function, including:• • • • •

More consistent decision making by operational supervisors. More appropriate sector configurations to manage sector traffic levels optimally and safely. Sector functions adequately developed and trained, with more clarity to support safe sector operations. More effective CAPC scheme leading to improved operational professional standards and more attention to controlling techniques and behaviours. Improved management and professional standards of controlling, including improved levels of Conformance.

Develop alternative measures of risk assessment that supports staff to get better at what they do, particularly with respect to sector configuration. Recognise what we do right for safety and extend this to all. Ensure that the organisational structure works collegiately to optimise safety and service. Ensure the organisation supports the correct balance to be maintained between safety and service. During CP3 we aim to:Improve the staff capability for Risk Management in the Operations Room and create the opportunity for experienced controllers to formally broaden their skills throughout their career.

Provide dedicated assessment and training activities that provide safety skills for the career as well as the role for managers and supervisors. Risk Factor

Action

Owner

Date

Preventative Safety: Capability

Develop and implement a mechanism to measure the ‘safety capability’ of key staff roles within NERL, e.g. GS and CAPC, to inform future capability building/ training Develop and implement a CPD programme for a) operational controllers and all supervisory functions b) FISOs and c) other operational functions (to be specified) a) Develop & b) implement new risk models/measures to support supervisors in management of sector operations in the operations room a) Explore and understand how the organisational structure inside and outside the Operations room supports – or fails to support – best service delivery with real operational safety and b) adapt structure accordingly

WS Lead

Mar 2012

WS Lead

a) b) c) a) b) a) b)

Preventative Safety: Capability Operational Risk: Sector Configuration Operational Risk: Organisational Structure

WS Lead WS Lead

Mar 2012 Mar 2013 Mar 2014 Oct 2012 Apr 2013 Jun 2012 Mar 2013

Reducing Our Risks

Reducing Our Risks Infringements & Class G Operations

Actual, Predicted and Target Risk for NERL Infringements Workstream 180

The Issue

Today

Improved ATC detection of infringing aircraft Improved GA postion awareness Airbox Aware Web based Flight Planning Tool Pilot Questionnaire

160

Prediction line if there was no safety improvement activity

100 80

Improved ATC detection of Infringing aircraft Non-NATS

60 40

NATS

Improved detectablity of all airframes

Overall Inf. Predicted Risk*

Inf. Risk Target

20 1

4Q 01 2

20 1

Q 1 4

13 Q

20 1

Q 3 3 20 1

1 Q 3

13 Q

20 1

4 12 Q 20

Q 2 20 1

2Q 2

Actual Risk

20 1

1Q 01 2

20 1

01 2

20 1

Q 4

01 2

20 1

Q 2

0Q 01

0 20 1

To remove the risk from Infringements into controlled airspace and operations outside controlled airspace by creating an aviation environment where all known data is available to all participants in the situation.

120

Strategic Objectives

Weighted SSE Index

140

Safety risks arise from infringements into controlled airspace or interactions outside of controlled airspace where no effective mitigation or safety net exists to prevent collision.

NERL Do nothing line

* Based o n Sept ember 20 10 Ba se Traffic Forecas ts

Risk Factor

Action

Owner

Date

GA Planning Awareness GA position Awareness Understanding Infringements Pilot Awareness of Airspace IFR Incomplete information Incomplete information Incomplete information Operating Environment Operating Environment

Produce a web based flight planning tool for GA pilots that will alert the user if the flight plan transits controlled airspace and create better visibility of GA flight plans for NATS Continue to promote the use of the Airbox Aware device commissioned by NATS to alert GA pilots when they inadvertently enter controlled airspace en route, and monitor uptake Continue to use a questionnaire for pilots who have infringed controlled airspace to allow NATS to better understand the reasons (including airspace design) and take action where appropriate Enhancement of situational awareness for IFR flights, especially with respect to airspace boundaries and type of airspace / service, by development of a GPS based device (e.g. Aware Lite) Sharing all known data for the benefit of the aviation community, e.g. airspace definitions, flight information and surveillance data so that external avionic suppliers can create new tools for pilots Increase the likelihood that the ATCO can communicate with the infringing pilot or airframe eg by promoting the use of monitoring codes and (in the longer term) targeted data communications Improve detectability of all airframes in all environments, either through emissions from the airframe or improved surveillance to generate a complete â&#x20AC;&#x2DC;known environmentâ&#x20AC;&#x2122; for Air Traffic Develop a Roadmap with CAA and other key stakeholders, to facilitate seamless and safe transition from CAS to Class G and vice versa, including technology, procedures, airspace and regulation Support airlines in conducting joint risk assessments of new routes that include segments in Class G, including sharing of hazard data and other supporting information

WS Lead WS Lead

Apr 2011 Apr 2013 Mar 2012

WS Lead

Mar 2012

WS Lead

Apr 2012

WS Lead

Oct 2013

WS Lead

Jul 2014

WS Lead

Mar 2015

WS Lead

Sept 2011

H Safety Swanwick

May 2011

Reducing Our Risks Example: In March 2009, a microlight aircraft, from Popham Airfield in Hampshire to a private strip in Suffolk, flew through the London Control Zone at low level, following the M25 motorway. The aircraft was not transponder equipped and generated only an intermittent primary radar return which was not initially detected by the controllers at Swanwick. The microlight passed within 200ft of a Boeing 737 departing from Heathrow. The subsequent investigation showed that the pilot had not properly planned the flight and traditional visual navigation techniques had failed without the support of any electronic airspace warning or orientation.

Targets FY 11/12:• Reduction in the infringements weighted SSE index by 10% based on the March 2011 figure. • The rate of infringements undetected by the controller to reduce by 10% each year • Infringements recorded for new airspace do not exceed the recorded number for the previous twelve months of the airspace prior to redesign/introduction. End of CP3:• Reduction in the number of infringements of airspace controlled by NATS by 30% on March 2011 figure. • No SSE 1/2 as a result of an infringement of airspace controlled by NATS in the final year of CP3.

Fig 9: This illustrates the type of orientation and airspace warning functionality that can be derived by the use of a simple but carefully specified GPS moving map device in the cockpit of a general aviation aircraft. NATS have helped specify such functionality in a number of devices on the basis of information gathered from detailed questionnaires targeted at infringing pilots and designed to understand the in depth circumstances which lead to an airspace infringement. This particular screenshot is taken from AWARE, a simple moving-map GPS conceived by NATS and produced by Airbox to help pilots stay orientated and to generate clear information about the airspace around them. AWARE is very simple to use and affordable to attract a large uptake in the GA community and in turn, to maximise the safety benefit to NATS.

Reducing Our Risks Level Busts

Actual, Predicted and Target Risk for NERL Level Bust Workstream 80

The Issue

Today

Prediction line if there was no safety improvement activity

Day to day safety measures

Weighted SSE Index

Business aviation capability workshops Barametric pressure setting tool

CFL/SFL at LTC 40

Non-NATS

Improvement in Altimeter setting errors HF study of inter-pilot comms Business aviation awareness campaign Review of phraseology

Actual Risk

Overall Level Bust Predicted Risk*

Q 4

Q 01 5

20 14

20 1

Q 01 4 2

01 3 2

20 1

Q 20 13

3Q 20 1

01 3

Q 01 2 2

20 1

1 Q

Q 20 12

12 20

20 11

Q 4

2 Q

01 1 2

Q 1

Q 10

20 11

Q 3 20 10

20 1

0 01 0

To mitigate risk from Level Busts by minimising the inherent risk in airspace design, alerting controllers in advance when the potential for a Level Bust arises and supporting operators and aircrew to continuously use the best known methods to ensure conformance to their cleared levels.

Strategic Objectives

20 1

Occasionally, aircraft unexpectedly deviate from, or fail to level off at, their cleared level. This may bring aircraft receiving a NATS service into conflict with other aircraft, creating risk of a Mid Air Collision. Additionally aircraft on approach to NATS airfields may deviate from their altitude clearance and risk Controlled Flight into Terrain (CFIT).

Level Bust Risk Target

NERL Do nothing line

* Based o n Sept ember 20 10 Ba se Traffi c Forecas ts

Risk Factor

Action

Lead

Date

Altimeter Setting Error Altimeter Setting Error Altimeter Setting Error Correct Readback / Incorrect Action Business Jets Radio Procedure Airspace Design Mode S Altimeter Setting Error Altimeter Setting Error Level Busts (General risk)

Implement BAT to alert controllers when an aircraft has incorrect pressure set, so that they can prompt the pilot to check Introduction of BAT above Transition Level to confirm 10.13.2 set for climbing aircraft, and work with manufacturers to enable all aircraft to downlink barometric pressure setting Complete a study with a volunteer airline, using ‘day to day’ observations on the flight deck to identify issues and improve altimeter setting procedures, to reduce altimeter setting errors. Work with other airlines will follow. Conduct a human factors study of inter-pilot communication including review of procedures to recommend improved SOPs and present to airline representatives at the SPA meeting. Target communications / information on level bust prevention to business jet pilots including web based facilities Trial new ‘challenge and response’ radio phraseology on departures to reduce vulnerability to error Review and improve airspace design locally and nationally – see Airspace & Procedures Hold workshops to expand and standardise use of Mode S down-linked parameters, recommend new applications Transmit Transition Level on ATIS, enabling pilots of new generation aircraft to set automatic warning on FMS to change pressure setting a) Birmingham and East Midlands b) LTMA Introduce technical advances to allow the Met Office QNH to be data-linked directly to aircraft and automatically updated within the aircraft instrumentation Develop and utilise the Level Bust Capability model, run stakeholder workshops, recommendations developed to ensure that actions taken to reduce level bust risk are targeted to give the greatest benefits

WS Lead

May 2011

WS Lead

Oct 2014

D Safety

Jun 2012

WS Lead

July 2011

WS Lead WS Lead D&I WS Lead WS Lead WS Lead

Mar 2012 Sept 2011 Mar2012 Jan 2012 a) Mar2011 b) Jun 2012 Dec 2014

WS Lead

Aug 2011

Reducing Our Risks Example: In July 2009, a Citation aircraft, from London City Airport, climbed above its cleared level into conflict with a Boeing 777 inbound to Heathrow. The departing pilot had read back his cleared level incorrectly and the error had not been detected by the controller. The two aircraft passed each other with 100ft and 0.5nm separation. Airspace and procedural changes followed.

Targets FY 11/12:• Reduction in total level busts per 100,000 movements by 10% based on the March 2011 figure. • The rate of losses of separation due to a level bust per 100,000 movements to reduce by 10% each year. • Reduction in the proportion of SSE A/B graded losses per 100,000 movements, by 10% each year. • Reduction by 10% of the Causal factor “correct pilot response incorrect action” and “correct response from incorrect aircraft” in all level busts based on March 2011 figure each year. • Level Busts recorded for new airspace do not exceed the recorded number for the previous twelve months of the airspace prior to redesign/introduction.

Fig 10: An operational First Officer carries out ‘Day to Day’ observations on his colleagues in the Simulator. This is a method used at NATS with Air Traffic Controllers.

End of CP3:• A reduction in the number of level busts from Business aviation aircraft by 40% on March 2011 figure. • A 40% reduction in level busts from altimeter setting errors compared with the March 2011 figure.

Instead of waiting for something to go wrong, trained observers watch whether the operational staff are Always / Sometimes / Never using the positive safety behaviours that are recommended to help prevent human error from creating safety risk. In this example, the tasks are focused around Altimeter Setting Errors, a process that is being studied in detail to reduce opportunities for error and ensure that robust procedures are routinely used by the crew. Flybe were the first airline to volunteer to work with NATS with this method.

Reducing Our Risks Civil Military Interactions

Actual, Predicted and Target Risk for NERL Civil Mil Workstream 60

Today

Improved defensive controlling techniques Common understanding of class F & G airspace Understanding of different aircraft peformance

The Issue

Non-NATS

Reduction in unexpected Mil interactions during exercises

NATS

Actual Risk

1 01 5Q 2

Q 4

Civil Mil Risk Target

20 14

4Q 20 1

01 4Q

4Q 20 1

01 3Q 2

Q 20 13

Overall Civil Mil Predicted Risk*

20 1

01 3Q 2

2Q 20 1

01 2Q 2

12 Q

20 12

20 11

Q 4

01 1Q

20 1

Q 1

10 Q

20 11

20 10

Q 3

0 20 1

To remove the unexpected interactions inside controlled airspace and minimise the risk to all aircraft operating in Class F/G airspace without unnecessarily restricting the flexibility of either operation. This will be achieved by creating a collaborative understanding of de-confliction services and risk management, and jointly agreeing and implementing procedural and technological solutions.

01 0Q

Strategic Objectives

Education of Military Pilots to CAS Awarness of CAS tool Prediction line if there was no safety improvement activity

Safety risks arise from unexpected interactions between civil and military aircraft within controlled airspace, or interactions outside controlled airspace where incompatible expectations lead to a perception of increased risk.

Weighted SSE Index

NERL Do nothing line

* Based o n Sept ember 20 10 Ba se Traffi c Forecasts

Risk Factor

Action

Owner

Date

ATC Performance ATC Performance

Enhancements to CAIT (includes reverse engineering to alert for danger area penetration) Improve defensive controlling by all PC ATCOs completing DefCon simulation (D2D measures) Tool to indicate in the military cockpit if the aircraft is inside or outside CAS (Aware Lite)

WS Lead PC Safety Coordinator Infringements WS Lead WS Lead WS Lead

Mar 2013 Apr 2012

D. Ops PC PC Head of Investigations Manager, Safety Improvement WS Lead

Dec 2011 Dec 2011

Military Awareness of CAS Enhancing Understanding Enhancing Understanding Common Understanding Common Understanding

In depth analysis of military infringements through questionnaire based data gathering Enhance data gathering and recording methods including Inside/joining CAS (TCAS, STCA, level busts) and Outside CAS (TCAS, STCA between known civil and other unknown traffic) A series of high level liaison visits to engage station commanders in the risk objectives MCRM courses for civil/military controllers and pilots â&#x20AC;&#x201C; focused on ATSOCAS

Common Understanding

Develop a joint NATS-Military method for event severity assessment

Common Understanding

Develop capability for strategic/pre-tactical de-confliction of civil and military operations (e.g. scheduling of planned activity against scheduled civilian traffic)

Jul 2012 Oct 2011 Dec 2012

Dec 2011 Apr 2013

Reducing Our Risks Example: October 2008: Two losses of separation occurred in Terminal control when a formation of two non-squawking Italian Eurofighter Typhoon aircraft made an unauthorised entry into controlled airspace. This resulted in a loss of separation against a McDonnell Douglas MD90 in the TC East sector and an Airbus A321 working the TC LAM sector. The formation was not squawking so the confliction was difficult for the TC East controller to detect, so no resolution was provided.

End of CP3: • A 50% reduction in unexpected interactions during military exercises (measured by 50% reduction in the number of events with “military activity” causal factors). • A 20% reduction in TCAS and STCA events between known civil and other unknown traffic arising from civil military interactions outside/ leaving controlled airspace.

The formation then recycled its squawk (on to an emergency code), but the controller’s attention was on traffic behind the A321 and so no resolution was provided by the controller. Neither the Military nor civilian Pilots were aware of each other and electronic systems such as TCAS do not operate against nonsquawking aircraft. Work is underway with UK MOD to improve management of exercises, especially those involving overseas military forces.

Targets FY 11/12:• A 20% improvement in D2D observed defensive controlling behaviours. • A 20% reduction in the number of interactions, indicating improved common understanding of Class F/G operations. • A 20% reduction in TCAS events and level busts arising from civil / military interactions inside/joining controlled airspace. • A 20% year on year reduction in the number of risk bearing infringements by military aircraft in CAS.

Fig 11: A pair of Typhoon fighter aircraft crossed the London TMA unexpectedly

Reducing Our Risks Oceanic Operations The Issue Today

Event Contracts Education and Training of Airlines & ANSPs

Prediction line if there was no safety improvement activity

Non-NATS 15

NATS Event Contracts Oceanic Safety improvement activities

Actual Risk

Oceanic Risk Target

1 5Q 01 2

Q 4

01 2

20 1

4Q 1

01 2

Q 13 20

3Q 1

01 2

Overall Oceanic Predicted Risk*

2Q 1 20

2 Q

2Q 01 2

1 Q 12

20 12

Q 4

1 20

2 01 1Q 2

11 20

Q 3

10 20

1 20

Strategic Objectives To reduce the risk in Shanwick Oceanic Operations through a structured education programme and pro-active involvement with airspace users, ANSPs and international aviation safety organisations. To promote technological improvements thereby creating an environment in which controllers are fully aware of the position of aircraft, and can identify and resolve actual and potential LHDs and GNEs in a timely and effective manner.

Actual, Predicted and Target Risk for NERL Oceanic Workstream 40

Weighted SSE Index

Oceanic Operations differ from domestic operations due to the lack of radar coverage and VHF communication. Although separations are larger than those applied in domestic airspace, any deviation by an aircraft from its planned flight profile or any loss of separation can remain undetected and hence unresolved for an extended period of time. In particular, there is an on-going issue with aircraft flying undetected at the wrong height â&#x20AC;&#x201C; these are termed LHDs â&#x20AC;&#x201C; and mean that operations over the North Atlantic do not meet the ICAO TLS in the vertical dimension.

NERL Do nothing line

* Based o n Sept ember 20 10 Ba se Traffi c Forecasts

Reducing Our Risks Risk Factor

Action

Owner

Date

Aircraft within Oceanic airspace at wrong height / route

With SRG, influence ICAO and Oceanic ANSPs to mandate ADS-C for all aircraft flying in â&#x20AC;&#x153;coreâ&#x20AC;? Oceanic airspace (to be defined)

31/11/12

Aircraft within or about to enter Oceanic airspace at wrong height / route Common understanding

Provide systems such that controllers have accurate and timely current and predicted position data for all aircraft in or about to enter Shanwick Oceanic airspace and the ability to contact them in a timely manner Improve incident investigations & lesson learning within NATS and with other Oceanic / adjacent ANSPs

NATS rep on ICAO Safety Oversight Group Work stream Lead

On-going

Common understanding

Hold a workshop each year with adjacent ANSPs and increase the understanding of oceanic operations and interface issues

Common understanding

Visit 3 targeted airline operators and help them to increase their understanding of oceanic operations, incident investigations and lesson learning

Common understanding

Have strong representation within ICAO groups to influence safety improvement activities

Common understanding

Through the ICAO Safety Oversight Group, monitor and communicate individual airline operator & ANSP safety performance and trends on an annual basis. Set targets for improvement

Head of PC Safety Investigations ANSP Interfaces lead Airline Interfaces lead NATS rep on ICAO Safety Oversight Group NATS rep on ICAO Safety Oversight Group

31/12/15

18/5/11 and then annually 31/12/11 and then annually 25/5/11 and then bi-annually 31/3/12 and then annually

Reducing Our Risks Example: In May 2010, an A320 from Porto to Dublin, was cleared northbound at FL350 with an estimate of 1107 for BEGAS. At 1109 a call was received from Madrid advising that the flight was passing BEGAS still at FL340 but climbing to FL350. Separation was lost with a westbound crossing flight through SIVIR at FL340. The flights were 7 minutes apart and crossing when 15 minutes was required. Madrid forgot to climb the flight and the crew forgot to request their cleared level prior to the entry point.

Targets Throughout CP3, against a baseline of 2010: • A 20% reduction each year in the number of aircraft entering Shanwick Oceanic airspace without a clearance • A 20% reduction each year in the number of aircraft entering Shanwick Oceanic airspace at a height or entry point that differs from its clearance By end CP3: • All aircraft flying in “core” Shanwick Oceanic airspace (to be defined by ICAO) are ADS-C equipped • Within “core” Shanwick Oceanic airspace, no aircraft spends more than 3 minutes more than 300ft from its cleared flight level • Within “core” Shanwick Oceanic airspace, no aircraft spends more than 5 minutes or more than 7nm from its cleared route • Current position data provided to controllers for aircraft in high risk areas of Shanwick Oceanic / adjacent airspace • Risk within Shanwick Oceanic airspace is within the ICAO Target Level of Safety, particularly in the vertical plane

Fig 12: Oceanic control is a unique skill as the operation is very different to other areas; currently controllers do not have traffic depicted on a radar image and manage their flights using flight information as shown above. To other controllers, this could feel more similar to Procedural Control than the Radar Control that most operations use today.

Reducing Our Risks Operational Interfaces

Actual, Predicted and Target Risk for NERL Operational Interfaces Workstream 250

The Issue

The Pilot/Controller Interface is vulnerable to misunderstandings caused by use of non standard phraseology and through a lack of common understanding/non-alignment of procedures and/or information. These misunderstandings can manifest themselves in incidents such as level busts and runway incursions.

Improved Operational Interface with Maastricht Work with Airlines to reduce pilot errors

200

Weighted SSE Index

Prediction line if there was no safety improvement activity 150

Non-NATS

100

Improved Operational Interfaces Awareness campaign with Airlines

NATS

1 5Q

Q 14

14 Q 20

Q 2

1 20

3Q 01 2

Op Interfaces Risk Target

3Q 1 20

3Q 01 2

Overall Op Interfaces Predicted Risk*

3 2Q

2Q 1

01 2

Q 2

1 20

01 2

Actual Risk * Based o n September 20 10 Ba se Traffic Forecas ts

4 1Q

11 Q

11 20

Q 1 11 20

3 0Q

0Q 1

01 2

Q 2 10 20

10 Q

0 20

Operational Interface safety risks may arise from the adoption of ineffective ATC procedures, non compliance with agreed procedures and the ineffective presentation of air traffic between sectors and units as a result of a lack of appreciation by the offering sector of the tasks required to be fulfilled by the receiving sectors. Aircraft operating outside controlled airspace do generate safety related incidents with aircraft joining or leaving controlled airspace and receiving an ATC service from NERL/ NSL. In addition there are specific sector interfaces that are targeted for review by operational staff; AC/TC (e.g. LAG South and TC South West); TC with London Airports, Southampton and Farnborough; PC and AC with other European ANSPs.

Today

NERL Do nothing line

Education and Alignment of Procedures – awareness for both pilots and controllers to promote a mutual understanding of each other’s working environment and ensuring that procedures (or method of operation) do not contribute to incidents.

Strategic Objectives

Sharing of safety data and joint safety plans – predominantly through the SPA. This will maximise the use of resource for safety related activities and encourage alignment of safety objectives.

To highlight and focus on those operational interfaces that NATS believes generates the highest risk to the operation.

Targets

To review specified intra and inter sector/ unit procedures to reduce the operational risk from the adoption and compliance of agreed ATC procedures and methods of operation across interfaces. A focus on specified interfaces will generate a greater understanding of the safety risks. A review of ATC procedures and MOPS will improve operational practices and defensive controlling techniques to improve safety performance.

FY 2011/12: A 20% reduction in non-conformance with LOA and agreed procedures observed during the follow up set of Safety in the Wild observations at each interface targeted. By end CP3: The operational interface work stream is looking to achieve a 40% reduction in Weighted SSE Risk Index sighting operational interface as a causal factor by March 2015 vs FY10/11.

Reducing Our Risks

Fig 13: Controllers work across many interfaces, including AC/TC, adjacent sectors, different airspace (e.g. controlled –uncontrolled) centres-airports, neighbouring ANSPs, military danger areas and – probably the most crucial interface of all – their interactions with the Pilots are key in effective control of traffic.

Example: May 2010. An SSE2 BCI650 lost separation with AUR543 on airway Q41, at ASPEN reporting point, whilst under control of Solent Radar. Whilst this is technically in NSL, TC traffic presentation to Solent Radar was contributory. The traffic inbound to Southampton can be considered in two pairs; BCI650/AUR543 and BCI248/BEE82K who were approximately 20 miles ahead, yet BCI650 and AUR543 were transferred first. Since the expectation was that the first pair would be transferred first, and callsigns were similar, there was confusion about which aircraft the controller was talking to when giving instructions. When BCI650 and AUR543 were transferred to Solent, neither aircraft had reached the release point (ASPEN) and were outside Solent’s area of operation, whilst BCI248 and BEE82K were passed the release point, approaching NEDUL and well within Solent’s area of responsibility before co-ordination and eventual transfer of control took place.

Reducing Our Risks Risk Factor

Action

Owner

Date

Complex interface arrangements

Use analysis, feedback and Day to Day Observations to identify the operational interfaces which create most safety risk due to ATC procedures or non compliance and develop a plan to reduce the associated risk. Develop a plan for reducing the number of instances pilots get a TCAS RA

AC & TC Safety Co-ordinators / UCE Managers Mgr SP&I, Swanwick Human Factors

Apr 11

Understanding the reasons for TCAS events Controllers mis-hearing or not hearing pilot transmissions Understanding the operational risk of Wake Vortex encounters Aircraft enter active danger areas as a result of inaccurate information Understand the impact to MOPs across operational interfaces as a result of ATC system change Ineffective interface procedures

Aircraft operating outside CAS unknown to ATC may conflict with aircraft joining and leaving Aircraft failure to follow ATC Procedures Procedure compatibility, particularly with reference to Transition Altitude. Traffic presentation and a lack of understanding of the tasks of receiving sectors/ units.

Understand the issues and develop a plan to mitigate against the risks of Controllers mis-hearing or not hearing pilot transmissions Develop a method to assess the safety risk of wake vortex encounters and assess the impact of FAA/ European plans for vortex re-categorisation Deliver a system to NERL Operations rooms to provide accurate and real time danger area and route availability information. Minimise any safety related incidents across operational interfaces as a result of the introduction of electronic flight data, i.e. a review of safety aspects by WSMs following the implementation of iFACTS into Swanwick (see Managing Change entry in Swanwick Safety Plan) Identify key operational interfaces where the parties involved collaboratively agree improvements can be made. Publish key findings to all operational staff at the specified interface to generate improved techniques, conformance with defined procedures and a better understanding of other ATC colleague’s tasks in adjacent airspace. Generate an awareness campaign and defensive ATC measures for the potential risks from aircraft operating outside CAS against those joining or leaving controlled airspace and receiving a service from NERL ATCOs (see Infringements/ Class G entry in Swanwick Safety Plan) Through a joint safety plan with the SPA, identify main causes and work with airlines to reduce occurrences and align procedures where appropriate Standardise procedures with reference to Transition Altitude across the UK/Ireland Functional Airspace Block. Conduct a “Receiving Sector Awareness” campaign to familiarise ATCOs of the tasks in adjacent sectors and how traffic presentation may assist.

TC WSM (Wake Vortex lead) Unit Development & Delivery team WSMs

Jul 11 Dec 11 Mar 12 May 12 Dec 12

WSM (TC) Safety Coordinator (AC)

Mar 13

AC WSM (ATSOCAS lead)

Mar 13

SPA

Mar 13

Unit Development & Delivery Teams AC & TC Safety Co-ordinators

Dec 13 Mar 14

Reducing Our Risks Afterword CP3 is a time of enormous change for NATS, with the Olympics in 2012, performance based navigation uptake in the airlines, significant new technical systems being implemented in our operation and the forecast return of higher traffic levels. Change presents challenges for safety; it takes our attention, we may have to do things in new and unfamiliar ways and we have to make sure that in the operation, the whole process is as seamless as possible. Our changes are carefully managed but any change has the potential to unsettle a stable situation. This means that we have to be especially vigilant in periods of major change.

increasingly aware of the potential for risks beneath the surface that have not yet manifested into events, we have unprecedented ability to collect data and model new situations and we are recognising the importance of managing human performance like never before. During CP3 we aim to continue our journey in learning to increase resilience and safety and our first steps have been set out in this strategic plan.

We may have a sense that some factors in our environment are increasing or reducing our safety risk, but measuring the level of risk with any certainty is more difficult. Itâ&#x20AC;&#x2122;s not an exact science, and the fact that one issue has a higher statistical risk does not make it the only risk to acknowledge. Risk is often viewed differently by different people, and even in a single organisation the risks perceived in the Operations Room may not be the same as those highlighted by statisticians. My own career in NATS has given me direct experience of both the operational and data driven perspectives. In truth, both have their value. I also believe that we could expand our sources of information to provide a more complete picture of both operational and event based information. This may mean collecting additional information or being smarter with our use of supplementary data and feedback that we already have. I am always conscious that the current economic climate is difficult and our customers are facing tough challenges of their own. We are keen to support them by working together and achieving economies of scale by collectively addressing safety issues through the SPA. We are delighted to be working with some airlines who are seeking to conduct safety improvements using techniques that we can facilitate with information or specific experience. Such collaboration is beneficial to us all.

David Harrison, Safety Director NATS

We are all facing challenges, yet we have also come a long way and are continuing to grow in our approach to inspiring safety. We are 44