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Safety Action

Summary

SAFETY ACTION

Airservices Australia advised that the safety actions in place following the incident or planned for implementation include:

  • The Group Tower Manager responsible for Hamilton Island has reinforced the need, through the Tower Manager, to ensure that the automatic terminal information system (ATIS) strip matches the actual ATIS broadcast
  • A review of the requirements of the visual separation requirements in the Manual of Air Traffic Services (MATS) was conducted to assure that all pertinent limitations were referenced and determined that no changes to MATS were required
  • A performance check will be completed every month for the first 3 months after an air traffic controller gets an initial rating, then at 6 months and then the checking regime will be in accordance with the requirements in the Civil Air Traffic Services Operations Administration Manual (target date for implementation is 30 June 2005).
Safety action update from Airservices Australia (dated 6 March 2008)

Following the ATSB investigation of this occurrence, Airservices advised of three safety actions in place or planned for implementation. All those actions were completed within the advised time frame. Airservices subsequently completed a review of the following action in respect of its application and benefit to the Air Traffic System.

A performance check will be completed every month for the first 3 months after an air traffic controller gets an initial rating, then at 6 months and then the checking regime will be in accordance with the requirements in the Civil Air Traffic Services Operations Administration Manual (target date for implementation is 30 June 2005).

This correspondence is to advise that Airservices has removed the prescriptive requirement to undertake these performance assessments and replaced it with a more generic requirement 'the assessor is encouraged to perform such additional performance assessment(s) as is/rare) thought appropriate to the individual circumstance in the early stages of the controller's consolidation in such a new Endorsement. This may for instance mean that a controller is formally re-assessed prior to the expiry of the normal currency period of 6 months'.

A follow up review indicated that additional guidance should be added such that 'particular consideration with regard to additional or more frequent assessments should be given to newly endorsed controllers who are not subject to regular supervision'. This guidance will be incorporated into the documents by end of May 2008.

APPENDIX A

Air Traffic Control Automatic Voice Recording - Hamilton Island ADC

Legend:

717 - Boeing 717 aircraft (`C/S 717' designates where the callsign of the aircraft is used in radio transmissions)
ADC - Aerodrome controller
737 - Boeing 737 aircraft (`C/S 737' designates where the callsign of the aircraft is used in radio transmissions)
SC - Brisbane sector controller
[…]- Unintelligible transmission

Only radio transmissions pertinent to the occurrence are included.

Time (EST)FromToRemarks
1613:04 717 ADC Hamilton tower C/S 717 requesting taxi with Quebec
1613:09 ADC 717 C/S 717 taxi enter backtrack and line up runway one four the time is one three
1613:14 717 ADC Enter backtrack line up runway one four C/S 717
1613:33 SC ADC Swampy
  ADC SC Taxies C/S 717 Sydney cleared via Mackay flight planned route flight level three one zero
1613:39 SC ADC Three one zero C/S 717
1614:10 737 ADC Hamilton tower good afternoon C/S 737 is on descent to six thousand three zero dme
1614:16 ADC 737 C/S 737 good afternoon Hamilton tower descend to five thousand report approaching with dme distance
1614:23 737 ADC C/S 737
1614:57 ADC SC Next in one is C/S 717 via Mackay
  SC ADC C/S 717 unrestricted
  ADC SC Unrestricted C/S 717
1615:15 ADC 737 C/S 737 about to roll runway 14 is C/S 717 outbound direct to Mackay I have him maintaining three thousand and you down to four thousand until we get a sighting
1615:30 737 ADC C/S 737
1616:55 717 ADC And C/S 717 is ready
  ADC 717/737 C/S 717 break C/S 737 your current dme distance hammo
1617:03 737 ADC C/S 737 is one six and we've just left six thousand
1617:10 ADC 737 C/S 737 roger descend to four thousand visual
1617:12 737 ADC Four thousand visual C/S 737
1617:16 ADC 717 C/S 717 maintain three thousand expect no delay at that level clear for take off make right turn
1617:22 717 ADC Three thousand clear for take off make right turn C/S 717
1617:30 ADC 737 C/S 737 report sighting a seven one seven about to roll runway […]
1617:36 737 ADC Eleven seventy four
1618:05 737 ADC C/S 737 is approaching four are we cleared to left downwind
1618:16 ADC 737 C/S 737 roger track now for a left downwind runway one […]
1618:24 737 ADC Roger and we have the seven one seven in sight
1618:28 ADC 737 C/S 737 roger cleared a visual approach report turning left base
1618:34 737 ADC C/S 737 roger
1618:39 737 ADC That will be a right base sorry
1618:41 ADC 737 Okay make that a right circuit and report on right base
1618:45 737 ADC C/S 737
1618:52 ADC 717 C/S 717 climb to flight level three one zero the other aircraft has you in sight
1619:00 717 ADC C/S 717 say again
1619:03 ADC 717 C/S 717 climb to flight level three one zero the other aircraft has you in sight
1619:07 717 ADC Flight level three one zero C/S 717
1619:10 ADC 737 C/S 737 just confirm you will be passing behind the seven one seven
1619:14 737 ADC Roger aah that's affirmative
  ADC 737 Thank you
1619:20     Ah […]
1619:33 ADC 737 C/S 737 tower um […] that aircraft in sight and were going to pass behind
1619:42 737 ADC And yeah and then he started to turn and we did not have any choice but turn left
1619:45 ADC 737 Understood

 

 
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