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OUR SAFETY MANAGEMENT SYSTEM AT WORK

OUR SAFETY MANAGEMENT SYSTEM AT WORK. Mitigating Altitude Deviations. 1. MEASURING SUCCESS. We measure success by the number of things we fix . 2. FIXING PROBLEMS HAPPENS LOCALLY. We must empower employees to solve their own safety risks. 3. PROACTIVE SAFETY.

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OUR SAFETY MANAGEMENT SYSTEM AT WORK

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  1. OUR SAFETY MANAGEMENT SYSTEM AT WORK • Mitigating Altitude Deviations • 1

  2. MEASURING SUCCESS • We measure success by the number of things we fix. • 2

  3. FIXING PROBLEMS HAPPENS LOCALLY • We must empower employees to solve their own safety risks. • 3

  4. PROACTIVE SAFETY • OUR SAFETY MANAGEMENT SYSTEM • 4

  5. THE SAFETY MANAGEMENT SYSTEM • COLLECT • FIND • FIX • 5

  6. THE SAFETY MANAGEMENT SYSTEM • 6

  7. GIVE EMPLOYEES THE MEANS TO ENGAGE • Partnership for Safety • Confidential Information • Share Program • Voluntary Reporting Programs • Prioritized Hazards to Mitigate • 7

  8. PARTNERSHIP FOR SAFETY • Over 200 lessons learned published in our ATC Infohub Database. • 8

  9. VOLUNTARY SAFETY REPORTING PROGRAMS • Leveraging experience and knowledge from frontline employees. • 9

  10. VOLUNTARY SAFETY REPORTING PROGRAMS • CY2008 • CY2009 • CY2010 • CY2011 • CY2012 • CY2013 • 14 • 1700 • 18,023REPORTS • 0 • Reporting participation rate is over 80%. • 10

  11. THE AIR TRAFFIC SAFETY REPORTING PROGRAM - ATSAP • Over 72,000 ATSAP reports filed and 200 positives. • 11

  12. THE CONFIDENTIAL INFORMATION SHARE PROGRAM - CISP • Leveraging knowledge from flight crews that operate in our NAS. • 12

  13. CISP REPORTING GETS RESULTS • 13

  14. THE PRIORITIES • 2012 • 2013 • 2014 • Turns to finalParallel runway operationsGo-aroundsClearance compliance altitudeCoordination • RecoveryTraffic advisories/safety alertsFailure to monitor initial departure headingsSimilar sounding call signsConflicting procedures • DistractionsCombining/de-combining positions/sectorsAircraft identity not maintainedPosition relief briefingsOn-the-job training instruction • National priorities for fixing safety hazards. • 14

  15. SAFETY IMPROVEMENTS • WE HAVE RESULTS • 15

  16. COLLECT • FIND • FIX • MITIGATING ALTITUDE DEVIATIONS (LEVEL BUSTS) • Monitoring and measuring our corrective actions. • 16

  17. ALTITUDE AND SPEED CHART FIX • BEFORE • AFTER • 17 • Departure navigation chart (pre and post change)

  18. ALTITUDE AND SPEED CHART FIX • BEFORE • AFTER • IMPROVEMENT: - Data positioned at relevant location • RESULT: - Greater pilot awareness • 18

  19. ALTITUDE DEVIATIONS • 19

  20. ALTITUDE DEVIATIONS • IMPROVEMENT: - Carrier updated air charts • RESULT: - Greater compliance • 20

  21. CISP POSITIVES • PDX Altitude Deviation • SFO Departure Altitude • ORD Route Confusion • Flight plan did not capture departure route or altitude. • Similar route names: • Aircraft descending below minimum altitude. • DENW1 • DEN1W • Airlines, FAA and NATCA • reviewed and made changes to the route names. • Safety Blast sent to all pilots and FAA design team to evaluate RNAV. • Airlines acted to make change in dispatch database. • Sample 2014 altitude deviation mitigations • 21

  22. THE SAFETY FACTORS • 2012 • The Risk Analysis Process determined these were the contributing factors: • Turns to finalParallel runway operationsGo-aroundsClearance compliance altitudeCoordination • Incorrect read back • Wrong aircraft readback • Controller missed readback • Frequency congestion • Blocked readback • Radio interference • Landline interference • Similar call signs • Misstated altitude • National priorities for fixing safety hazards. • 22

  23. THE MITIGATIONS • Our Safety Management System determined these were clearance compliance altitude mitigations: • 2012 • Turns to finalParallel runway operationsGo-aroundsClearance compliance altitudeCoordination • Did not implement • conflict alert parameter change • ATSAP - Safety Briefings • LOAs - Pilot Training • Partnership with NATCA, ALPA & AOPA • Mitigated similar call signs • RNAV – Procedures Review • PBN – Procedures Review • Mode-S still under review • National priorities for fixing safety hazards. • 23

  24. THE HIGH RISK EVENTS • Parallel Runway Operations • FY2013 • FY2013 • FY2012 • FY2012 • Clearance Compliance Altitude • Taking actions and monitoring efforts produces positive outcomes for safer operations. • 24

  25. IT IS ALWAYS CHANGING • Future technologies will create new safety challenges. • 25

  26. The Top 5 shows the full scope of the ATO’s SMS at work. • 26

  27. MEASURING SUCCESS • We measure success by the number of things we fix. • 27

  28. OUR SAFETY MANAGEMENT SYSTEM AT WORK • Mitigating Altitude Deviations • 28

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