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Safety Action

Summary

In their investigation report dated 23 October 2000 Airservices Australia recommended that:

  1. The effectiveness and efficiency of procedures and defences associated with the incident should be analysed and gaps or weaknesses addressed as a matter of priority (including Systems Configuration Controls).
  2. The configuration of the Sydney UPS System should be reviewed as a matter of urgency.
  3. A review of the document control procedures for Maintenance Services documentation should be conducted.
  4. The adequacy of design and configuration of the loads for the UPS should be reviewed with regard to maintaining the safety of the Air Traffic System and exposure to single point failures.
  5. The risk assessment process used in the assessment of the operational impact associated with works planned activities should be reviewed.
  6. The content and frequency of refresher training for ATC in degraded modes procedures and simulation should be reviewed as a matter of priority to ensure safe and timely actions through practised response and full understanding of system responses.
  7. National and local contingency plans in Brisbane, Melbourne and Sydney should be reviewed with regard to outcomes of the incident.
  8. Published communication failure procedures should be reviewed and an analysis of aircrew responses during the incident to those procedures be conducted.
  9. The directed traffic information position at Sydney Terminal Control Unit be fitted with an air to ground bypass.
  10. The effectiveness and efficiency of procedures and ATC responses associated with the incident should be reviewed by a local safety panel.
  11. A risk assessment of TAAATS workstations be conducted to establish whether there should be a redesign for mini-UPS for the Sydney Terminal Control Unit workstations.
  12. Consideration be given for the development of ATC workstations that have the ability to retain the air situation display to support the situational awareness of Air Traffic Controllers.
  13. Consideration be given to establishing printed phone numbers of adjoining ATC units, combined with a separate physical keypad for accessing the PABX in ground to ground bypass mode in the event of TAAATS screen failure.
  14. A Failure Modes Effects and Criticality Analysis be conducted at all remote Terminal Control Units to measure and address the risk associated with the hazard of UPS power failure.
  15. A review of the configuration of the Sydney TCU "fallback" system source of power be conducted.

RECOMMENDATIONS

As a result of this investigation the Australian Transport Safety Bureau makes the following recommendations.

R20000294
The Australian Transport Safety Bureau recommends that Airservices Australia introduce Team Resource Management Concepts as part of electrical technical officer initial and recurrent training.

R20000295
The Australian Transport Safety Bureau recommends that Airservices Australia perform a task analysis to determine what tasks electrical technical officers carry out. From this task analysis, role clarification should be developed.

R20000296
The Australian Transport Safety Bureau recommends that Airservices Australia review the content of Airways Engineering Instructions for the maintenance and testing of UPS equipment.

R20000297
The Australian Transport Safety Bureau recommends that Airservices Australia review the design of STARS and Instrument approaches with a view to improving separation assurance during communications or radar failure.

R20000298
The Australian Transport Safety Bureau recommends that Airservices Australia review curfew operations in regard to providing a greater level of segregated airspace.

R20000299
The Australian Transport Safety Bureau recommends that Airservices Australia review the training of electrical technical officers on operational equipment.

 

 
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