Aviation safety investigations & reports

Boeing Co 767-324, VH-BZF, 3 km WNW Melbourne, (VOR) 18 March 1999

Investigation number:
Status: Completed
Investigation completed


A Beech 1900 (Beech) departed from runway 27 and was tracking via a STRATHBOGIE 8 standard instrument departure, on climb to 5,000 ft. Shortly after, a Boeing 767 (B767) departed from runway 34 on a DOSEL 8 standard instrument departure, on climb to 5,000 ft. The standard instrument departure tracks intersected approximately 2 NM north of the aerodrome. The departure north radar controller (departure controller) observed that the separation between the two aircraft was not going to be maintained and queried the aerodrome controller in relation to the separation procedure being applied. The aerodrome control position was being operated by a trainee under the supervision of a rated controller. The trainee advised that he thought the departure controller was providing separation. The departure controller instructed the Beech crew to turn left onto a heading of 310 degrees and the B767 crew to turn right onto a heading of 030 degrees. The two aircraft passed at the same altitude, with 1 NM lateral separation. The minimum separation required was either 3 NM laterally or 1,000 ft vertically. There was an infringement of separation standards. The B767 was fitted with a traffic alert and collision avoidance system and the crew received a traffic advisory just prior to the issue of the avoiding instructions from the departure controller.

The trainee and the aerodrome controller had been at the console for about 3 hours and the number of aircraft being managed had reduced slightly following a busy period. The runway mode was being changed from land and hold short operation (LAHSO) using runways 34 and 27, to dedicated departure runway arrangement using those runways. In LAHSO all aircraft depart from runway 27, while in the dedicated departure mode, departures to the south and west use runway 27 and those to the north and east use runway 34. In that configuration, the intersection of aircraft departure tracks is almost eliminated. It was recognised by experienced controllers that the transition period between runway modes required an increased awareness and careful consideration of the traffic management plan to ensure that potential conflicts for departing aircraft were minimised. The trainee was aware of potential problems for each mode but had not been alerted to the potential problems that may occur during a mode transition period. On taxi, the crew of the B767 requested and were approved to use runway 34. The trainee subsequently amended the departure order of the B767 and the Beech to eliminate a requirement to apply a 2 minute wake turbulence separation standard to the Beech aircraft.

The trainee did not appreciate that the aircraft's departure tracks converged north of the aerodrome. The aerodome controller reported that as the trainee was soon to be checked for a rating his monitoring of the trainee's control was less vigilant than normal. Local instructions stated that the aerodrome controller was responsible for the separation of departing aircraft within 5 NM of the aerodrome and that for departures from different runways, the aerodrome control and departure control positions were jointly responsible for coordinating a separation solution. The departure controller's preference was to depart the B767 before the Beech but he agreed to the trainee's request to change the departure order. Normal practice in this situation was that the aerodrome control position, having initiated the change, was responsible for the separation unless otherwise coordinated. The controllers neither coordinated a separation solution nor clearly established who was responsible for ensuring separation. Both assumed that the other was going to separate the two aircraft. The aerodrome controller was not aware of the developing situation and was only alerted to the infringement following the departure controller's query to the trainee.

The trainee had undergone tower control ab initio training, which included approximately 1 day of training on the vectoring of aircraft. The course did not provide any terminal area (TMA) control training. Controllers undergoing training for tower positions were able to undertake TMA familiarisation. But, the tower training syllabus did not require trainees to develop an understanding of, or to be familiar with, TMA operations. TMA familiarisation by tower trainees was conducted on an ad-hoc basis and there was no procedure to assess a trainee's level of understanding of TMA operations.

Melbourne Tower training publications did not provide advice of a preferred duration for training sessions that would maximise the training benefit. The publications did list aspects of critical safety that needed to be covered during training for both trainees or supervising controllers. But, the list did not include areas of known conflict for standard instrument departures or standard arrival routes. The publications did not include advice of the potential inherent complexity of runway mode transition.


The concentration level of both the aerodrome controller and the trainee had probably lapsed due to the duration of the training session. Additionally, the aerodrome controller may have been less vigilant in his monitoring of the trainee because of the reduction in aircraft numbers and his perception of the trainee's level of competence in the aerodrome control position.

Provision of information regarding the increase in complexity of traffic management during runway transition and regarding the critical safety aspects of standard instrument departures and arrivals would have provided the trainee with some knowledge to compensate for areas where he lacked experience. On-the-job training does not necessarily expose trainees to all critical elements nor provide sufficient time for them to develop their own traffic management models. Information on such critical areas is required to ensure that safety aspects are understood and considered, particularly during on-the-job training.

A greater awareness of terminal area operations and procedures may have provided the trainee with sufficient knowledge to appreciate that the departing aircraft were not going to be separated by the departure controller. In turn, this may have alerted the trainee to the fact that he was required to provide a separation solution or alternatively coordinate one with the departure controller.

Significant Factors

  1. The supervisor of the trainee, the aerodrome controller, had a lapse in concentration at a critical stage of the departure sequence, having been operating at the position in excess of 3 hours.
  2. The trainee was unfamiliar with terminal area operations/procedures and was unaware of the increase in complexity during runway transition.
  3. Tower training publications' critical safety section and other references did not include potential standard instrument departure or arrival areas of conflict.

Safety Action

Local safety action

As a result of the investigation, Airservices Australia Southern District have proposed to:

  1. amend the Melbourne tower training syllabus to ensure that ab initio trainees gain a broad range of experience prior to commencing aerodrome or coordinator training;
  2. require trainees and controllers supervising training to attend a training principles briefing pending the introduction of a workplace training course in the near future;
  3. impose a maximum training session duration of 2 hours; and
  4. amend local instructions relating to traffic management procedures and the use of non-duty runways.

Australian Transport Safety Bureau (ATSB) Safety Action

The ATSB is investigating safety deficiencies relating to:

  1. ab initio aerodrome controller rating training; and
  2. the identification and publication of critical safety areas including the level of separation assurance provided by standard instrument departures.

Any safety outputs issued as a result of the investigation will be published in the Bureau's Quarterly Safety Deficiency Report.

General details
Date: 18 July 1999   Investigation status: Completed  
Time: 1822 hours EST    
Location   (show map): 3 km WNW Melbourne, (VOR)    
State: Victoria   Occurrence type: Loss of separation  
Release date: 24 March 2000   Occurrence category: Incident  
Report status: Final   Highest injury level: None  

Aircraft 1 details

Aircraft 1 details
Aircraft manufacturer The Boeing Company  
Aircraft model 767  
Aircraft registration VH-BZF  
Serial number VH-BZF  
Type of operation Air Transport High Capacity  
Damage to aircraft Nil  
Departure point Melbourne, VIC  
Departure time 1821 hours EST  
Destination Sydney, NSW  

Aircraft 2 details

Aircraft 2 details
Aircraft manufacturer Beech Aircraft Corp  
Aircraft model 1900  
Aircraft registration VH-IMH  
Serial number VH-IMH  
Type of operation Air Transport Low Capacity  
Damage to aircraft Nil  
Departure point Melbourne, VIC  
Departure time 1820 hours EST  
Destination Williamtown, NSW  
Last update 13 May 2014