Our Safety Management System at Work

Mitigating Altitude Deviations

Draft v1.3

Taking Action

Taking Action

We measure success by the number of things we fix.

Managing risk means we are actively mitigating safety hazards and monitoring our performance. Taking action and then measuring outcomes over long periods of time will ensure a safer NAS.

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We must empower employees to solve their own safety risks.

Safety is local; performed one operation at a time by frontline employees. We value the knowledge and expertise in our workforce and we actively promote their participation in facility safety councils.

People

Proactive Safety

Proactive Safety

Collect, Find and Fix

The Safety Management System is summarized in three action steps. Everyone, everywhere, everyday in the NAS is engaged in one of these actions. All safety programs are aligned to the principles of the SMS, which enable FAA employees to proactively reduce potential sources of risk.

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    Collect

    Collect

    Report

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    Find

    Find

    Compile, Analyze, Identify

    Find Icons
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    Fix

    Fix

    Improve

    Fix Icons

Safety Programs that Work

As vital parts of the SMS, each program is designed to have direct impacts on NAS safety.

Over 200 lessons learned published in our ATC Infohub Database.

Leveraging experience and knowledge from frontline employees.

Leveraging knowledge from flight crews that operate in our NAS.

National priorities for fixing safety hazards.

Voluntary Safety
Reporting Program

The ATO values the safety knowledge in frontline employees. As a result, controllers are making significant contributions to safety initiatives. Data received through the ATSAP system means analysts have credible information that provides context from the radar scope and the tower cab.

VSRP Graph
ATSAP Mobile

ATSAP

More than 72,000 ATSAP reports have been filed, with more than 200 positives.

Safety analysts issue monthly briefing sheets via mobile platforms so controllers and managers across the NAS benefit from safety notices.

Confidential Information
Share Program

The ATO values the safety contributions made by pilots. Gaining insight and context from the cockpit perspective allows safety analysts to more accurately find and identify potential hazards that can lead to safety risk. And, sharing safety data between pilots and controllers is having a positive effect on NAS safety.

7,213

CISP reports exchanged 2013

CISP reports exchanged 2013

5,100

Reports submitted by airlines to FAA

Reports submitted by airlines to FAA

2,113

Reports submitted by FAA to airlines

Reports submitted by FAA to airlines

19

Participating airlines

Participating airlines

The Top 5

National safety priorities are mitigated and monitored for long periods of time to ensure outcomes are desirable and are contributing to overall aviation safety.

  1. Turns to final


  2. Parallel runway operations


  3. Go-arounds
  4. Clearance compliance altitude


  5. Coordination
  1. Recovery
  2. Traffic advisories/safety alerts
  3. Failure to monitor initial departure headings


  4. Similar sounding call signs
  5. Conflicting procedures
  1. Distractions
  2. Combining/de-combining positions/sectors
  3. Aircraft identity not maintained


  4. Position relief briefings


  5. On-the-job training instruction

Safety Improvements

Safety Improvements

Monitoring and Measuring our Corrective Actions

The Safety Management System comes full circle when we can effectively measure our performance. As we verify the results of our safety mitigations, we continue to collect data and analyze the information to ensure continued success. Only by monitoring and measuring corrective actions do we have confidence that our safety performance is improving.

Leveraged Knowledge

ATSAP reports and the Confidential Information Share Program identified cockpit workload and poorly designed air navigation charts were causing confusion leading to altitude busts at Chicago O’Hare three departure.

Improvement: Data positioned at relevant location
.
Result: Greater pilot awareness.

Leveraged Knowledge

International carriers were consistently violating arrival procedures and maintaining incorrect altitudes enroute to San Francisco International Airport. Working with air carriers, the ATO discovered that flight management systems were not updated with the latest information. Once the FMS software was updated, the altitude deviations were eliminated.

Improvement: 
Carrier updated air charts
.
Result: 
Greater compliance.

CISP Positives

Sample 2014 altitude deviation mitigations.

ORD

ORD Route Confusion

Similar route names: DENW1 vs DEN1W.
Airlines, FAA and NATCA reviewed and made changes to the route names.
PDX

PDX Altitude Deviation

Aircraft descending below minimum altitude.
Safety Blast sent to all pilots and FAA design team to evaluate RNAV.
SFO

SFO Departure Altitude

Flight plan did not capture departure route or altitude.
Airlines acted to make change in dispatch database.

Clearance Compliance Altitude

The Risk Analysis Process determined the contributing factors.

Incorrect read-back
Wrong aircraft read-back
Controller missed read-back
Frequency congestion
Blocked read-back

Our Safety Management System determined the clearance compliance altitude mitigations*.

ATSAP - Safety Briefings

LOAs - Pilot Training

Partnership with NATCA, ALPA & AOPA
Mitigated similar call signs

RNAV - Procedures Review

PBN - Procedures Review


*Did not implement conflict alert parameter change. Mode-S still under review.

The Top 5 High Risk Events

Taking action and monitoring efforts produces positive outcomes for safer operations.

Top 5 Graphs

Conclusion

Conclusion

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The Future

The Safety Management System is designed to advance air traffic control by allowing the FAA to safely introduce new technologies and procedures into the NAS. By more fully integrating the SMS and applying the principles farther upstream to include acquisition programs and advanced science, the FAA ensures the safety of each flight.

The Safety Management System

We are committed to safety and efficiency as the core mission of the FAA. By using our Safety Management System we will continue to drive potential sources of risk down and improve our performance. In the FAA, safety is everyone, everywhere, everyday.