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Safety Action

Summary

As a result of this investigation, and a number of similar occurrences, the Bureau of Air Safety Investigation issued a report (B98/90) of an investigation of systemic issues at the Sydney Terminal Control Unit. Nine recommendations were made in the report, the following four of which are considered valid for this investigation:

"R980157
Airservices Australia review the application of the "teams" concept within the Sydney Terminal Control Unit to ensure that teams are resourced appropriately and that there is an ongoing commitment to the provision of adequate training in order to achieve a high level of controller proficiency and standardisation."

"R980158
Airservices Australia ensure that adequate refresher training is undertaken by controllers in order to provide for high levels of controller proficiency and standardisation and so that the integrity of safety cases, in which refresher training is deemed to be a mitigating strategy for identified hazards, is maintained."

"R980159
Airservices Australia reassess the human factor hazard analysis for both Stage One and Stage Two of the LTOP safety cases so that the mitigating strategies applied to identified hazards adequately allow for the fundamental limitations of human performance. In reassessing this hazard analysis, BASI recommends that Airservices Australia seek the assistance of human performance expertise."

"R980160
Airservices Australia consider restructuring the current roster operating in the Sydney Terminal Control Unit to ensure that contemporary fatigue management research is translated into meaningful duty hour regulations. In any restructure of the roster, BASI recommends that Airservices Australia expand its absentee management program to include individuals who expose themselves to the risks of fatigue by participating in excessive amounts of overtime and/or emergency duty."

 
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