Normal Operations Safety Survey (NOSS)
Liberty University
AVIA 409 - Safety Management Systems
Professor: Andrew Walton
2022
NOSS Background
In observing the business-like approach to safety underlying Safety Management Systems (SMS), it
is evident that in order to sustain safety in the modern aviation system, a proactive data collection
methodology, to complement the existing reactive systems, is required. To that end, electronic data
acquisition systems and non-jeopardy self-reporting programmes were introduced to collect safety data
from normal operations. The latest addition to these proactive safety data collection methodologies are
data acquisition systems that are based on direct observation of operational personnel during normal
operations.
NOSS was introduced by recommendation 2/5 of the Eleventh International Civil Aviation
Organisation (ICAO) Air Navigation Conference, held in Montreal in 2003, which reads: “That ICAO
initiate studies on the development of guidance material for the monitoring of safety during normal air
traffic service operations, taking into account, but not limited to, the line operations safety audit (LOSA)
programmes which have been implemented by a number of airlines.”
Although NOSS is different from LOSA in many respects, there are also similarities in the
methodology applied by both. NOSS and LOSA are both based on the Threat and Error Management
(TEM) framework. NOSS was developed with the assistance of the ICAO NOSS Study Group and is based
on a similar method used in the flight deck environment.
Overview and Brief Description
The Normal Operations Safety Survey (NOSS) is a methodology for the collection of safety data
during normal air traffic control (ATC) operations. A normal ATC operation is defined as an operation
during the course of which no accident, incident or event takes place of which the reporting and/or
investigation are required under existing legislation or regulations. Training and check shifts are
considered to be outside the scope of normal operations.
By conducting a series of targeted observations of ATC operations over a specific period of time,
and the subsequent analysis of the data thus obtained, the organisation is provided with an overview of
the most pertinent threats, errors and undesired states that air traffic controllers must manage on a
daily basis. One feature of NOSS is that it identifies threats, errors and undesired states that are specific
to an organisation's particular operational context, as well as how those threats, errors and undesired
states are managed by air traffic controllers during normal operations. The information thus obtained
will enhance the organisation's ability to proactively make changes in its safety process without having
to experience an incident or accident.
Relationship to the Safety Management System
NOSS is designed to complement existing safety data collection sources. Its added value is that it
provides data from normal operations (as opposed to abnormal occurrences during operations), and it is
not occurrence-driven like most of the existing mechanisms. NOSS can be scheduled at any time that is
suitable for the organisation, to sample the systemic safety performance in daily operations and to
provide an overview of the organisational strengths and weaknesses in the management of threats,
errors and undesired states during normal operations. The organisation can subsequently act on the
outcome of a NOSS before safety issues manifest themselves through occurrences.
Safety data from NOSS are data that are not otherwise available. As such they complement the
traditional sources of data of a safety management system. NOSS is regarded as a component of an ATC
safety management system (SMS), as a safety management tool.
As such NOSS is a tool that assists air traffic services providers to comply with Annex 11, 2.2.7.3 c), i.e. to
“provide for continuous monitoring and regular assessment of the safety level achieved”.
Scope of NOSS
NOSS is a method developed for application in the operational environment and has ten
specific operating characteristics. Rather than being a tool to assess individual controller behaviour or
controller productivity, NOSS will provide the organisation with a picture of the most pertinent threats
and errors in a specific operation, how they are managed and how effectively any resulting undesired
states are managed during normal ATC operations.
Purpose of NOSS
The purpose of conducting a NOSS in an organisation is to find out what are the most pertinent threats
and errors that controllers have to manage during normal operations and how these are managed. NOSS
thus captures ATC system performance through the eyes of the air traffic controllers. Once that
information is available, the SMS of the organisation can propose adjustments in the operational
processes as required (e.g. changes in procedures, or specific safety topics for recurrent training
programmes for air traffic controllers) as countermeasures to the threats and errors that the controllers
are confronted with on a daily basis. By conducting follow-up NOSSs, an organisation will be provided
with feedback on the effects of its safety change process since the previous NOSS.
Added Value of NOSS
Conventional safety data collection programmes mainly present data from abnormal operations, i.e.
data about situations that went wrong, or failed system/human performance data. Furthermore, data
collection is traditionally outcome-driven, i.e. some triggering event must take place in order for the
programme to capture safety data. NOSS provides data about normal situations, i.e. where situations
resulted in uneventful outcomes, or successful system/human performance data. The NOSS data include
information about the effect of specific countermeasures on managing threats, errors and/or undesired
states, which is an indication of the success of existing safety strategies in the operations of the
organisation. Furthermore, NOSS data are process-driven, i.e. there is no need for a triggering event to
take place in order for the programme to capture safety data.
Benefits of NOSS
Proactive hazard identification
Prioritized safety actions
Enhanced understanding of air safety incident trends
Converging lines of evidence
Identification of areas of strength
Improved organisational trust
Engaged workforce
Positive cooperation with the regulator
Exchange of information, industry benchmarking and collaboration with airlines
Decision support tool
Verification of the quality and usability of procedures
An understanding of controller shortcuts and workarounds.
Specific Objectives of NOSS Implementation
After conducting a NOSS, the organisation will be able to set clear targets for safety enhancement
of its operations. The effect of changes made can be “measured” by conducting a follow-up or repeat
NOSS. In the meantime the effect of changes may be noticeable by comparing specific events trends
from the pre- and post-NOSS periods.
Framework of NOSS
NOSS is based on the Threat and Error Management (TEM) framework as developed by the
University of Texas. TEM is a conceptual framework that assists in understanding, from an operational
perspective, the interrelationship between safety and human performance in dynamic and challenging
operational contexts. The TEM framework focuses simultaneously on the operational context and the
people discharging operational duties in such a context. The use of TEM thus provides a common
framework that can assist in addressing multi-disciplinary issues in the aviation industry through the
exchange and analysis of safety data from normal aviation operations.
Prerequisites For NOSS
Before NOSS is conducted in an organisation a careful preparation for NOSS should be carried out.
There has to be agreement from both the management of the organisation and the body or bodies that
represent(s) the air traffic controllers. In the agreement the non-disciplinary nature of the data
collection process must be emphasized. Furthermore a mechanism has to be agreed for securing the
collected data and for preventing that data from being misused. It should be clear that NOSS data are
not designed to be used for incident investigation or research purposes. Organisations require a process
independent from NOSS for capturing safety data in the event of an incident or accident.
NOSS Data
The data from a NOSS programme are intended for use by the SMS of the air traffic service provider
organisation that conducts the NOSS.
Where is a NOSS Conducted?
NOSS observations are conducted at the normal operational working position(s) of the observed
controller(s). The observers should be as unobtrusive as possible while conducting their observations.
Subjects of NOSS Observations
NOSS observations will not be held in on-the-job (OJT) training or check situations. In a typical
observation session, lasting up to 1 hour and 30 minutes, a single controller working position will be
observed, even if the controller observed is working with another controller as part of a team. Observed
controllers will know that they are being observed, and they will also know the purpose of the
observation. Controller participation is voluntary, i.e. a controller can refuse to be observed for NOSS
purposes.
NOSS Observers
The observers for a NOSS programme are selected from the pool of qualified air traffic controllers
in the organisation. This selection may involve a joint effort by staff representatives and the
management of the organisation. Experience has shown that observers provide optimal data when
observing in a setting outside the one they normally work in; therefore consideration should be given to
selecting candidates from other facilities or positions than the one(s) where the NOSS will be held.
Candidate observers may also be selected from the (non-operational) instructor group in the
organisation, or from outside the organisation. As a general guideline the number of operationally
qualified observers should be no less than 80 per cent of the total number of observers. This adds to an
enhanced perception of the validity of the data because the data are collected by peers rather than
“outsiders”. The observations are performed by single (individual) observers.
NOSS Observer Training
The observer training and data collection is an important element of the pre-data collection phase.
The training will normally last up to 5 working days. Focus in the training programme is on the TEM
framework, as the observational concept that will guide observers towards what they are expected to
look for, and on how to fill in the observation forms. The last days of the training programme comprise
“controlled” observations, in which the completed observation forms are analysed with the observers in
order to help ensure the consistency and reliability of reports from different observers.
NOSS Data Collection and Processing
All data collected by the observers are reported in a de-identified format in order to guarantee the
anonymity of the controllers involved. After all data have been collected, data verification is performed
by selected observers and key staff from the organisation verify all received reports and the coding of
the threats, errors and undesired states as applied by the observers. Specialists subsequently analyse
the data. Next a detailed report of the results and findings from the NOSS is presented to the
management of the organisation.
NOSS Data Ownership and Storage
The data from a NOSS is owned by the ATS provider organisation that conducted the NOSS.
However NOSS data are sensitive material that could potentially be abused if taken out of context.
Therefore a trusted site should be selected and assigned to store the data after they have been collected
and analysed. Circumstances that can help determine whether or not an air traffic services provider
should store NOSS data in-house comprise inter alia: the national legislation on freedom of information
(i.e. to the press and the public), the status of the air traffic services provider (e.g. part of the
government or a corporatized entity) and, last but not least, the need to be able to benchmark or
otherwise compare the data with other organisations where a NOSS has been done. Alternative
locations for storing NOSS data could include, but are not limited to, universities or aviation research
laboratories in the State or region of the air traffic services provider.
