ATSAP Brief

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Narrative: Safety is the ATO’s highest priority. It is represented in the ATO’s Vision of Safety, Service and Value. While the ATO is working to improve efficiency and reduce the cost of service provision, safety remains the paramount focus of the ATO, just as it is for the entire FAA.

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Narrative: The diagram depicts the evolution of a safety culture. Patrick Hudson of the Centre for Safety Science at the University of Leiden, developed the model by building upon Westrum’s safety culture evolution model. The first stage is the Pathological stage, in which employees only care about whether they will get caught doing the wrong or unsafe thing. Next is the Reactive stage in which safety is a focus, but only in response to an accident or incident. In the Calculative stage, the organization has systems in place to manage all known hazards. The Proactive stage, is the stage in which employees anticipate and prevent problems before they occur. The final stage is the ideal state, which is called the Generative stage. In the Generative stage, safety is an integral part of how business is done. In the words of Russ Chew, ATO COO, “Safety is our service”. Safety awareness and trust at all levels increases as an organization’s safety culture evolves from passive to a more involved active approach to safety. Understandably the safety culture and the organization have to be adaptable and must be able to minimize the unknown. Hudson spoke of this awareness when he wrote, “Informedness follows from being informed (seeking information) and reporting (providing information). Trust follows from being just and from being informed, knowing that even bad news can be told and accepted for what it is, information to be acted upon. Adaptability follows from being flexible and learning. Finally being worried is a healthy state that follows from a combination of being informed and a belief that, even when things appear to be going well, life is not always fair, which provides the reason why the culture is wary.”

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Narrative: On the next slide, you will watch an abbreviated version of a video on the Challenger disaster. This video is an excellent example of the impact that culture has on safety.

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Explain that the contact information will be used by the analyst only to request additional information to clarify or complete a report. Messages sent to your email account will only notify you that a message or information about your report is available on the ATSAP website for your review. No Specific Information will ever be sent over the internet. The preliminary background is a series of check boxes, and fill in the blanks that detail your facility, operating position at the time of the event and other items about the event necessary for the analyst research the event in detail.

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1 Air Traffic Safety Action Program 1 Introducing ATSAP The Air Traffic Safety Action Program ATO, NATCA and AOV WARNING: The information in this document may be protected from disclosure under 49 U.S.C., section 40123 and 14 CFR part 193. PRIVILEGED AND CONFIDENTIAL

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2 Air Traffic Safety Action Program 2 Safety …. Our highest priority The ATO, NATCA, and AOV are working jointly to improve the safety culture of our organization. The next level of our efforts is to implement ATSAP, a voluntary, non-punitive employee safety reporting system.

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3 Air Traffic Safety Action Program 3 Safety Culture Evolution PATHOLOGICAL Who cares as long as we’re not caught Chronically Complacent REACTIVE Safety is important, we do a lot every time we have an accident CALCULATIVE We have systems in place to manage all hazards PROACTIVE Anticipating and preventing problems before they occur GENERATIVE Safety is how we do business around here Chronically Aware Increasing Trust *Adapted from Safeskies 2001, “Aviation Safety Culture”, Patrick Hudson, Centre for Safety Science, Leiden University Increasing Awareness Where we are today. Where we need to be.

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4 Introducing ATSAP Besides OEs/ODs/PEs/RIs, what types of events are reportable? Anything that you feel is a safety risk to the NAS, for example: Unsafe Policy/Procedures (National or Local) Poor/Confusing airport signage/markings Equipment/Software problems Traffic Management Initiatives that don’t properly address sector needs Aircraft Operating Procedures Airspace Configuration Human Factors Unsafe/Inadequate Training Practices Air Traffic Safety Action Program

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5 Air Traffic Safety Action Program 5 The Move to a Just Culture Our current culture, with our informational “blind spot”, could be described as a culture which has failed to recognize inherent operational risks. We have not taken appropriate measures to ensure the safety of key operations. To fill in our organizational blind spot we must move from our current blame and punitive based culture to a just culture. A just culture is neither blameless nor punitive A just culture is an atmosphere of trust in which people are encouraged to provide essential safety related information. Participants are clear about where the line is drawn between acceptable and unacceptable behavior

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6 Air Traffic Safety Action Program 6 Principles of a Just Culture Learning from unsafe acts Know the border between acceptable and unacceptable behavior How to decide on culpability; systemic versus individual

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7 Air Traffic Safety Action Program 7 Potential Challenges to Evolving the Just Culture A Just Culture is outside of our current experience The belief that safety is good, and cannot be improved, or a feeling that the organization is the best it can be. “Safety was never compromised”, or “We are currently experiencing the safest period in aviation history.” Previous lack of focus on trust building and information sharing Employees are uncertain we will follow through with our promise of a non-punitive environment Difficulty in breaking through the bureaucracy Change is difficult

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8 Air Traffic Safety Action Program 8 A Just Culture supports learning from unsafe acts Failures and incidents are considered by organizations with good safety cultures as lessons which can be used to avoid more serious events Any event related to safety, especially human or organizational errors, must be considered as a valuable opportunity to improve operations through experience, feedback, and lessons learned Voluntary reporting by employees is indicative of a constructive attitude and such an attitude will tend to prevent future violations Learning From Unsafe Acts

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9 Air Traffic Safety Action Program 9 The difficult task is to discriminate between the truly ‘bad behaviors’ and the vast majority of unsafe acts to which punitive action is neither appropriate nor useful. It is necessary to agree on a set of principles for drawing this line between negligence (without intent) and recklessness Negligence – involved a harmful consequence that a ‘reasonable’ and ‘prudent’ person would have foreseen Recklessness – involved one who takes a deliberate and unjustifiable risk Defining the Border Between “Acceptable” & “Unacceptable” Behavior

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10 Air Traffic Safety Action Program 10 Accepted Unsafe Acts - Human Error - Negligence (Without Intent) Unacceptable Behavior - Reckless Conduct - Intentional “Willful” Violations Defining the Border Between “Acceptable” & “Unacceptable” Behavior

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11 Air Traffic Safety Action Program 11 Excluded events Noncompliance that is not inadvertent Events that involve gross negligence Substance abuse Controlled substances Alcohol Intentional falsification Criminal activity Introducing ATSAP

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12 Air Traffic Safety Action Program 12 Introducing ATSAP In exchange for voluntary reporting of safety events: ATO agrees not to decertify or take disciplinary action for events covered by accepted reports AOV will take lesser action or no action

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13 Air Traffic Safety Action Program 13 Covered Employees: ATSAP applies to all air traffic personnel engaged in and supporting air traffic services, and only to events that occur while acting in that capacity. Introducing ATSAP

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14 Air Traffic Safety Action Program 14 Covered Events: Reports of events involving apparent noncompliance with applicable air traffic control directives that are inadvertent “Inadvertent” is determined by the ERC (Event Review Committee) Must be reported in a timely manner Within 24 hours of the end of the shift on which an event occurred Within 24 hours of first notification of an event when the employee did not/could not have known of the event Introducing ATSAP

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15 Introducing ATSAP Event Review Committee (ERC): Three member board made up of a representative of ATO, NATCA, and AOV. The ERC is the main driver of the ATSAP. ERC decisions are facilitated by a strong support structure consisting of the ATSAP Manager and a group of analysts who manage the software, reports, and any follow-up investigations that may be necessary to allow the ERC to fully analyze the reports and obtain necessary data to make a proper intelligent decision on the reports. The decision making process will be tied to understanding a Just Culture with collaboration between the ATO, NATCA and AOV. The decisions are made through consensus, which means that a voluntary agreement between all parties of the ERC must be reached.

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16 Introducing ATSAP ERC ERC will be formed as necessary to handle the number of reports generated. It is anticipated that two ERC’s will be required per Service Area. At present there are two ERC’s in the Central Service Area, one terminal and one enroute The ERC Meets once per week – and may meet as necessary or via teleconference for specific actions required. Air Traffic Safety Action Program

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17 Introducing ATSAP ERC Duties and Responsibilities: The ERC shall review and analyze reports under the program, identify actual or potential safety problems from the information contained in the reports, and propose solutions for those problems The ERC shall provide feedback to the individual who submitted the report. Directs fact-finding (if necessary) Makes corrective-action recommendations Individuals No action Skill enhancement Organization System corrective action Closes reports Air Traffic Safety Action Program

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Sample Response from ERC Closed - No Action Thank you for participating in the ATSAP Program. The Event Review Committee (ATO, NATCA, and AOV) has discussed your report. The information you provided will help us identify the threats and errors that have an impact on the safety of our air traffic system. The information gained through ATSAP reports might not be discovered by any other means. ATSAP report data leads the way to positive changes in procedures and training.   The ERC unanimously agreed your event can be closed with no further action on your part.   If you have any questions, you may contact the ATSAP Manager at 1-866-384-0157.   Sincerely, The Event Review Committee       Air Traffic Safety Action Program 18

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19 Air Traffic Safety Action Program 19 ATSAP process: Employee files a safety incident report online Toll-free line available to initiate a report when unable to file on-line ATSAP manager and analysts conduct fact finding and de-identify the report The ERC reviews the report Accepted/not accepted decision Accepted events are categorized for analysis and trending ERC has three possible responses; no action, skill enhancement or system corrective action. The vast majority will be no action. Skill enhancement and system corrective actions are accomplished confidentially by the facility as directed by the ERC Introducing ATSAP

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20 Air Traffic Safety Action Program 20 When an individual observes a safety problem or experiences a safety-related event, he or she should note the problem or event and describe it in enough detail so that it can be evaluated by someone (ERC and ATSAP analysts) not directly involved that understands air traffic risk. Details from each report will provide better data to help improve safety in the NAS ATSAP Web-Based Reporting

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21 Current Safety Assurance Process Air Traffic Safety Action Program

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Known Vs. Unknown Events An Unknown Report is a sole source generated report where an individual observes what they believe was an unsafe occurrence This satisfies your requirement to notify management Facility is unaware of the occurrence There may be multiple sole source reports from i.e. Developmental, Instructor, two separate controllers on either side of a boundary, R-side, D-side, tracker, etc… A Known Event is a an event in which Management is aware and the QA process has begun The individual is afforded the opportunity to file an ATSAP report The QA process and ATSAP process will run in parallel Management and FACREP may forward recommendations to ERC The Facility QA investigation will be forwarded to ERC Air Traffic Safety Action Program 22

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23 ATSAP Process for Unknown Events Air Traffic Safety Action Program

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24 ATSAP Process for Known Events Air Traffic Safety Action Program

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25 Managements Role in ATSAP Except as described below, the submission of an ATSAP report satisfies an employee’s obligation to report any occurrence that may be an operational deviation; operational error, proximity event, or an air traffic incident if the reported issue is known only to the employee and occurs while the employee is directly providing air traffic services to aircraft or vehicles or first level watch supervision (acting as an FLM or CIC). 1. If the occurrence is observed by an employee providing first level watch supervision and the occurrence is known only to that employee, the employee providing watch supervision must report the occurrence in accordance with FAAO 7210.56; or file an ATSAP report on the occurrence. 2. If the occurrence is reported to an employee providing first level watch supervision, the employee providing watch supervision must report the occurrence in accordance with FAAO 7210.56; and may file an ATSAP report on the occurrence. 3. In situations where an individual employee is responsible for operational and watch supervision positions combined and experiences an event that is known only to that employee; they may elect to report in accordance with FAAO 7210.56; or file an ATSAP report on the occurrence, or both. Air Traffic Safety Action Program

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26 Air Traffic Safety Action Program 26 The ATM must: 1. Supply all information requested by the ATSAP manager/analysts and accomplish all skill enhancement/system corrective actions as recommended by the ERC. 2. Complete FAAO 7210.56 paragraphs 5-1-9b or 5-1-9c(1)(a), if applicable, forward proposed skill enhancement or return to duty (RTD) training to the ATSAP Manager and/or ERC Chairperson within three administrative days of the event for consideration by the ERC. Supportive information should accompany any recommended corrective action. 3. Keep confidential, to the extent feasible, information requested by, and all skill enhancement training recommended by the ATSAP Manager/ERC. 4. Take no decertification, or disciplinary action for events covered by an accepted ATSAP report. Facility Manager Responsibilities

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27 Affect on Employee after a Known Event For a PE or Low conformance event: Employee shall be offered the opportunity to file an ATSAP report, completes required investigatory requirements, shall be returned to work IAW FAA Order 7210.56. For a Moderate or High conformance event: Employee shall be offered the opportunity to file an ATSAP report, completes required investigatory requirements, may be returned to work on none, some or all positions, may be required to complete “Safety Check”, or may request a “Safety Check”. Air Traffic Safety Action Program

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28 Air Traffic Safety Action Program 28 Safety Check: An undocumented observation period requested by an employee, or required by an employee’s manager.  The objective of the observation is to confirm the employee’s individual self-confidence in their ability to provide air traffic services after a serious safety event. Note: No RTD plan or follow-up skill checks related to the event will be accomplished; any follow-up action will be directed by the ERC. Affect on Employee after a Known Event

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29 Affect on Employee after a Known Event No disciplinary action may be taken. The employee shall not be de-certified. Performance Skill Checks shall not be conducted unless directed by the ERC. Employees not immediately returned to operational duty shall be assigned Administrative Duties. Employees shall not be forced into a leave or non-pay status while awaiting the ERC decision. The employee’s schedule and Regular Days Off shall not be changed without the employee’s concurrence. Air Traffic Safety Action Program

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30 ATSAP Skill Enhancement Training Objective to training is to increase proficiency, and to assist in controller’s professional development. Skill Enhancement Training logged as Type 4 Training Recorded as “ATSAP” Not Pass/Fail Shall not be used for performance management Focus on proficiency and professional development Must complete training to be covered under ATSAP. Allows for recommendation to the ERC from Management and Facrep in a known event. Not meant to be punitive, or to merely “check” a box. Different, outside the box Air Traffic Safety Action Program

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31 Air Traffic Safety Action Program 31 ATSAP Report Handling Employee feedback follows each report Pop-up with a report number Report acknowledgement from the analysts If appropriate, any corrective action assigned Report is closed Corrective action is tracked and completion is reported back to ERC Report Closure is dependent on the completion of the recommended training

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32 Air Traffic Safety Action Program 32 Web-based reporting allows reports from any computer with internet access Does not require reports from work location Does not require you to use a FAA.GOV email address Permits secure entry of data, even if partial report is discontinued, then finished later Data is maintained by a contractor at secure location Quickly allows analysis of each report ATSAP Web-Based Reporting

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ATSAP Web-Based Reporting Narrative statements are broken down into data points to develop metrics that will contribute to safety improvements in the NAS Trends are reported to the ERC, ATO, AOV, and NATCA executives. De-identified individual reports may become safety data shared with all employees in newsletters and safety reports. Air Traffic Safety Action Program 33

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34 Air Traffic Safety Action Program 34 ATSAP Web-Based Reporting Individual submitter can view their reports by logging into the website. Incomplete Reports Modified Reports Open Reports Archived Reports

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35 Air Traffic Safety Action Program 35 ATSAP Web-Based Reporting Toll-free line allows report confirmation when internet access is not available Call ensures that ATSAP office notification is recorded Details of the safety event are not left on recorded line ATSAP office will follow-up with the submitter Report must be filed in three-days Time extension may be approved under certain circumstances Assistance with the electronic submission will be offered

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www.ATSAPsafety.com Air Traffic Safety Action Program

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37 After Successful Login Air Traffic Safety Action Program

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38 Message Waiting On Server All Correspondence Stays On The Secure Server Air Traffic Safety Action Program

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39 Employee Information X Air Traffic Safety Action Program

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40 Contact Information Page Air Traffic Safety Action Program

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Contact Information Air Traffic Safety Action Program

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42 ATSAP Submission Form Air Traffic Safety Action Program At this point you may select the button, and you now have 3 days to finish and submit your ATSAP report. The “24 hour clock” is stopped.

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Submission Form = 2+30 = 9+00 = 6+45 = 5+00 = 8+10 Format Examples Want: Date & Shift Start Time Do Not Want: D, D, M, RDO, RDO, N, N Air Traffic Safety Action Program Check All That Apply When Positions Are Combined

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44 Submission Form Air Traffic Safety Action Program

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45 Submission Form Air Traffic Safety Action Program

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46 Submission Form Air Traffic Safety Action Program

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47 Submission Form Air Traffic Safety Action Program Your opinion of risk to the NAS

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48 Submission Form Offer Specific Details Of The Event Air Traffic Safety Action Program

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49 Submission pop-ups ATSAP Report Receipts Report acknowledgement from the analysts within a few days Air Traffic Safety Action Program

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Finish An Incomplete Report Air Traffic Safety Action Program

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51 Finish An Incomplete Report Air Traffic Safety Action Program Click on the underlined number to open INCOMPLETE report

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52 Sample Feedback from ERC Air Traffic Safety Action Program

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53 Contact Information ATSAP Manager: 1-202-314-1438 FAA Training Team: 1-202-236-2390 NATCA Training Team: 1-800-266-0895 Ext 28727 ATSAP Hotline: 1-866-384-0157 www.ATSAPsafety.com You Can Make A Difference! Air Traffic Safety Action Program

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