LHD MITIGATION MEASURES IMPLEMENTATION PROGRESS BY TRINIDAD AND TOBAGO BASED ON AN SMS APPROACH. (Presented by Trinidad and Tobago)

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1 International Civil Aviation Organization Seventeenth meeting of the GRPCAS Scrutiny Working Group (GT/7) Lima, Peru, 3 October to 3 November 27 GT/7-IP/8 3//7 Agenda Item 3: Large Height Deviation (LHD) Analysis LHD MITIGATION MASURS IMPLMNTATION PROGRSS BY TRINIDAD AND TOBAGO BASD ON AN SMS APPROACH (Presented by Trinidad and Tobago) SUMMARY This information paper contains an LHD analysis for the Piarco FIR/CTA/UTA for the period 29 to 26 with special focus on 26 and the progress made by mitigation measures that have been adopted in an attempt to keep the occurrences as low as reasonably practicable. RFRNCS: - ICAO Annex 9 - Safety Management. ICAO Strategic Objectives: A - Safety B - Air navigation capacity and efficiency 2. Introduction 2. Piarco FIR/CTA/UTA is adjoined by nine (9) adjacent FIRs/CTAs (Appendix A), namely, San Juan (TJZS), New York (KZNY), Santa Maria (LPPO), SAL (GVSC), Dakar (GOOO), Cayenne (SOOO), Paramaribo (SMPM), Georgetown (SYGC) and Venezuela (SVZM). The AP has been recording and analysing reportable LHD occurrences attributable to Piarco for a period of at least seven (7) years from 29. This data is disseminated to CARSAMMA monthly. Various strategic approaches are used in an attempt to mitigate the occurrences attributable to Piarco. 3. Discussion 3. Appendix B, provides data collected on LHD occurrences attributable to Piarco Area Control Centre () from 29 to 26. The trend over the last seven (7) years has shown a general decrease of such occurrences. In an attempt to mitigate occurrences, the AP employs a number of strategic approaches mentioned below. - Gathering and assessing safety data associated with the LHD occurrences (Appendices B, C, D and ); - Collaboration with AP Departments (e.g. ATS, AIM and C); - xchanging of safety data and collaboration with APs responsible for providing ATS in the adjacent FIRs/CTAs; - xchanging of safety data and collaboration with concerned airline operators; - Generating safety awareness through:

2 GT/7-IP/8-2 - Remedial actions inclusive of safety de-briefings performed with the concerned A Staff, and Dissemination of Information Bulletins related to LHD occurrences to A Staff. 3.2 Since employing the strategic approaches, the AP has observed a decreasing trend (Appendix B) in the number of LHD occurrences attributable to Piarco from 2 onwards. It is hoped that there is a direct correlation between the strategic mitigation approaches and the observed decreasing trend. 3.3 Our assessments have shown that practical drift and the non-adherence to Standard Operating Procedures (SOPs) play major roles in the occurrence of LHDs attributable to Piarco. 3.4 In the future the AP has therefore taken the decision to include the following strategies: - Implementing a Normal Operations System Survey (NOSS) Programme; - Implementing a Voluntary Reporting Programme; - Continuance in addressing Threat and rror issues associated with practical drift and the coordination of flights between Piarco and Adjacent APs; - Written and Oral Knowledge Verification Tests (KVTs) as part of ATS Proficiency Checks. ATIs and ATs to be subjected to biannual Proficiency Checks with an higher pass mark required; - Continuance in reinforcing the importance of adhering to SOPs; - Scheduled refresher training every two years; - Identifying and introducing Quality Assurance Officers on each Shift; - Upgrade of the ATM System and implementation of AIDC; - Possible implementation of Radar handhoffs with adjacent FIRs/CTAs and TMAs; and - ncourage voluntary use of the Critical Incident Stress Management (CISM) Programme and mployee Assistance Programme (AP) to help deal with work stress related issues that can impact performance. 4. Suggested actions: a) The Meeting is invited to note the information contained in this paper

3 GT/7-IP/8 APPNDIX A Piarco s FIR/CTA/UTA with Adjacent FIRs/CTAs

4 Number of LHD Occurrences GT/7-IP/8 APPNDIX B LHD Occurrences Attributable to Piarco for the Years 29 to September 26 YAR MONTH JANUARY FBRUARY 4 2 MARCH APRIL MAY 2 JUN 2 2 JULY AUGUST 3 3 SPTMBR 2 OCTOBR NOVMBR 2 2 DCMBR TOTAL Total Reported LHDs Attributable to Piarco 2 5 Trend Line Year

5 GT/7-IP/8 APPNDIX C Details of LHD Occurrences Attributable to Piarco for 26 RROR ATTRIBUTD TO:. PIARCO NAX PIARCO FWI54 NO OF RRORS RSULTING FROM SAN JUAN CRAP coordinated NAX673 with PIARCO at position TIKAL at FL37. After initial contact with PIARCO, the aircraft requested descent north of position TIKAL. PIARCO did not attain approval from SAN JUAN CRAP and descended the aircraft to FL25. NAX673 crossed position TIKAL descending out of FL335. SAN JUAN CRAP called PIARCO to inform them that they observed the flight descending in SAN JUAN'S airspace. PIARCO inadvertently coordinated FWI54 with NW YORK ARTCC at position BNJ maintaining FL35. The flight checked position BNJ at 223UTC climbing out of FL29 for FL35. NW YORK ARTCC called PIARCO to confirm the estimate passed. LHD CATGORY COD SCTOR INVOLVD NON- COORDINATION RROR IN COORDINATION 3. PIARCO IB665 IB665 was erroneously coordinated with NW YORK ARTCC at position 8N4755W at 73UTC FL37. NW YORK ARTCC called PIARCO to state that IB665 checked 8N4755W at O63UTC. OS 4. PIARCO CRL925 PIARCO did not coordinate CRL925 with NW YORK ARTCC at position DRDG. The aircraft checked position DRDG at 2UTC F PIARCO JBU386 PIARCO coordinated JBU386 with SAN JUAN CRAP at position ILURI at 72UTC F34. At the cockpit crew's request, PIARCO recleared the flight to F36 and did not pass the level revision to SAN JUAN CRAP. The flight entered SAN JUAN CRAP'S airspace at F36. SAN JUAN CRAP called PIARCO to inform of the non-revised coordination. 6. PIARCO TAM PIARCO PU3 8. PIARCO BWA6 TAM899 was maintaining FL35 in PIARCO'S airspace, when PIARCO coordinated the flight with PARAMARIBO at position DOLRO at FL33. The flight checked position DOLRO at F35. PARAMARIBO called PIARCO to inform of the erroneous coordination. PIARCO received an estimate on PU3 via a CPL for position KNUT from SANTA MARIA OCANIC. Based on the filed FPL, the flight would have exited PIARCO'S airspace at 822N4435W, fly for six (6) minutes in NW YORK'S AIRSPAC and re-entered PIARCO'S airspace at position BUTUX. The estimate for 822N4435W would have been 6UTC. PIARCO forgot to coordinate this estimate with NW YORK ARTCC. After PU3 entered NW YORK'S airspace, the AP contacted PIARCO to attain information on the flight and this was provided with such. BWA6 departed from TTPP and was coordinated climbing to F37 by PIARCO with GROGTOWN. The flight requested F3 and was so cleared by PIARCO. The revised level was not coordinated with GORGTOWN. After BWA6 crossed position MINDA, GROGTOWN contacted PIARCO to confirm the level that the flight was coordinated at. SS OS SWS TOTALS 8 2 6

6 JANUARY FBRUARY MARCH APRIL MAY JUN JULY AUGUST SPTMBR OCTOBR NOVMBR DCMBR Number of Occurrences Number of Occurrences GT/7-IP/8 APPNDIX D LHD Occurrences Reported by Piarco for 26 LHD Occurrences PIARCO SANTA MARIA MAIQUTIA PARAMARIBO ATTRIBUTABL AP LHD Occurrences Attributable to Piarco for MONTH

7 GT/7-IP/8 APPNDIX Assessment of LHD Occurrences Attributable to Piarco for 26 Type and percentage of LHD Occurrences for 26 Attributable to Piarco Non- Coordination 25% [CATGORY NAM] [PRCNTAG ] Percentage of LHD Occurrences in Piarco's Operational Sectors for 26 Adjoining FIRs/CTAs: SYGC SMPM SOOO GOOO GVSC LPPO KZNY Adjoining FIRs/CTAs: SYGC SVZM South-West Sector [PRCNTAG] Oceanic & South- ast Sectors [PRCNTAG] North Sector [PRCNTAG] Adjoining FIRs/CTAs: SVZM TJZS KZNY OS & SS SWS