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Safety Action

Summary

Recommendations

As a result of the investigation into this occurrence, the Bureau of Air Safety Investigation issued the following recommendations:

IR970014

"The Bureau of Air Safety Investigation recommends that Airservices Australia review the requirements detailed in AIP Supplement H73/96, (10 October 1996) Simultaneous Opposite Direction Parallel Runway Operations Sydney (KSA) and:
  1. develop a SID which incorporates a standard left hand turn after takeoff, and tracks the departing aircraft through the heads of Botany Bay in accordance with accepted separation and noise-abatement procedures,
  2. have the departing aircraft remain on tower frequency until the assigned turn has been completed, and
  3. develop a pilot aid for inclusion in departure and approach procedures (DAP) East. This chart should depict the expected flight path of aircraft departing and arriving under SODPROPS, and could be similar to the pilot-aid (Issue 1, 14 September 1995), located in DAP East, advising pilots about independent visual approaches at Sydney Airport."

Response from Airservices Australia received 4 March 1997:

"BASI has made three recommendations arising from Occurrence 9700052

Airservices has recently conducted a post implementation review (PIR) into SODPROPS at Sydney. Specific action undertaken by Airservices to address the BASI recommendations is as follows:

  1. An appropriate SID will be developed which will be standard for all departures from Rwy 16L (not specific to SODPROPS). Until then the RADAR 6 departure with specific headings will continue to be used.

    The BOTANY BAY HEADS Visual departure is no longer considered practical for jet aircraft owing to the difficulty in navigating to the Heads with high body angles and the possibility of entering cloud above 3000 feet prior to reaching the Heads.

  2. An instruction has been issued requiring ADCs to instruct departing aircraft under SODPROPS to remain on Tower frequency until established in the appropriate left turn.
  3. The recommendation to produce a pilot aid for inclusion into DAP (East) has been referred to CASA Flying Operations Branch for consideration/action.

While supporting these recommendations, Airservices is concerned that the report does not address the principle causal factor of the occurrence, namely flight crew error.

No reference is made to the following factors:

The assigned heading was correctly read back by the pilot but not entered into the FMS;

The pilot called departures radar at the appropriate time but failed to read back the assigned heading;

The use of FMS below the LSALT."

Response classification: Closed-Accepted

Response received from the Civil Aviation Safety Authority 22 April 1997:

"I refer to BASI Interim Recommendation IR 970014 addressed to Airservices Australia concerning Simultaneous Opposite Direction Parallel Runway Operations (SODPROPS) at KSA Sydney. The following comments are provided from a CASA perspective.

The first point of the recommendation is that "a SID be developed which incorporates a standard left hand turn after take-off and tracks through the heads of Botany Bay in accordance with accepted separation and noise abatement procedures". The SODPROPS standard is a visual standard and obviously the last line in separation would be the visual element. The ATC procedures specified in the local instruction indicated that a Botany Bay visual departure should be issued to departing aircraft. CASA believes there is no point in developing a Standard Instrument Departure (SID) for a visual procedure, in fact it could stop pilots from looking outside.

The second point is that the departing aircraft should remain on the tower frequency until the departure turn has been completed. Airservices Australia have since implemented this.

Finally, it is recommended that a pilot aid on SODPROPS be developed. This is probably worthy of consideration but CASA believes that AIP SUP H73/96 may require amending to specifically indicate a section on departing aircraft. Other than a reference in the standard section to course divergence there is no specific indication regarding aircraft departure requirements."

Response classification: Closed-Accepted

R970150

"The Bureau of Air Safety Investigation recommends that Airservices Australia conduct a comprehensive systems safety analysis of simultaneous opposite direction parallel runway operations (SODPROPS)."

The Bureau also made the following recommendation (R970151) to the Civil Aviation Safety Authority:

"The Bureau of Air Safety Investigation recommends that the Civil Aviation Safety Authority review the Operational Standard "Simultaneous Opposite Direction Operations" to ensure that it provides an acceptable level of safety."

Response received from Airservices Australia 1 December 1997:

"I am writing in response to your occurrence report and the associated recommendation that Airservices "conduct a comprehensive systems safety analysis of simultaneous opposite direction parallel runway operations (SODPROPS).

In addressing this recommendation, I commissioned a team to conduct an independent analysis of the SODPROPS procedure itself and the analysis that was conducted prior to the implementation of the procedure at Sydney Airport. This team comprised representatives from ATS' Safety and Quality Management Branch, [and] ATC specialists from Sydney and Brisbane. The team was assisted by expert support from CASA and the major domestic airlines.

In essence, the analysis team has produced a Safety Case (copy enclosed) addressing the safety issues identified by the original SODPROPS implementation team. This Safety Case has been augmented by a Fault Tree Analysis of the risk of failure of the SODPROPS procedure.

I must emphasise that the bulk of the analysis presented in the SODPROPS Safety Case reflects the extensive hazard analysis and risk mitigation work that was done by the implementation team prior to the implementation of SODPROPS.

Whilst it can be said that the data was not collated into a concise document (for which CASA and Airservices now advocate a Safety Case), the data was available in relevant files within the Sydney management system at the time of the BASI investigation.

The data used in this report was available in relevant files within the Sydney management system at the time of the BASI investigation.

The Fault Tree Analysis was compiled using probability data on human performance and on historical incident data. The SODPROPS Safety Case provides the necessary assurance that SODPROPS is being operated at an acceptable level of safety."

Response classification: Open

R970151

"The Bureau of Air Safety Investigation recommends that the Civil Aviation Safety Authority review the Operational Standard "Simultaneous Opposite Direction Operations" to ensure that it provides an acceptable level of safety."

The Bureau also made the following recommendation (R970150) to Airservices Australia:

"The Bureau of Air Safety Investigation recommends that Airservices Australia conduct a comprehensive systems safety analysis of simultaneous opposite direction parallel runway operations (SODPROPS)."

Response received from the Civil Aviation Safety Authority 27 November 1997:

"I refer to your letter dated 1 October 1997 reference BS/970061 regarding Recommendation R970151.

CASA has reviewed the Operational Standard "Simultaneous Opposite Direction Operations" as you have recommended. Following Occurrence 9700052 on 5 January 1997 the instructions in AIP OPS paragraph 19.4 were changed by NOTAM to require pilots to remain on Tower frequency until instructed to change, thus enabling Tower to correct the kind of confusion evident during the occurrence. The amendment will be correctly inserted into the AIP OPS text by AIP Amendment List 20, effective 4 December 1997.

Given the change to procedures our conclusion is that the standard expressed in the CASA Manual of Operational Standards (MOS) Part 3 Chapter 5.9 is adequate.

The MOS standard will be further reviewed in the light of any study which may be undertaken by Airservices in response to your recommendation R970150."

Response classification: Open

Following the provision of the SODPROPS safety case the Bureau elected to have the document reviewed by an independent consultant with international experience in aviation risk management practices and procedures. The intent of the review was to ascertain whether the safety case undertaken by Airservices was a comprehensive safety case and whether it had adequately demonstrated that SODPROPS could be conducted at a reasonable level of safety.

The review of the safety case was conducted in the last week of March 1998. On receipt of the consultant's report it will be reviewed and any further action by the Bureau will be subject to the findings of the report.

 
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