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Using all information to monitor separation risk

Issue number: AR-2012-034-SI-03
Who it affects: All civilian aircraft operations into military controlled airspace
Issue owner: Civil Aviation Safety Authority
Operation affected: Aviation: Airspace management
Background: Investigation Report AR-2012-034
Date: 18 October 2013

Safety issue description

Loss of separation (LOS) incidents attributable to pilot actions in civil airspace are not monitored as a measure of airspace safety nor actively investigated for insight into possible improvements to air traffic service provision. As about half of all LOS incidents are from pilot actions, not all available information is being fully used to assure the safety of civilian airspace.

Response to safety issue by: Airservices Australia

In response to the report's observation that Airservices does not actively investigate or monitor pilot-attributable LOS incidents Airservices would like to clarify that our primary focus on the investigation of ATS-attributable occurrences is to effectively prioritise our internal resources and learning effort on Airservices systems, processes and people. Airservices also actively monitors LOS incidents deemed attributable to pilot actions through the daily safety review of all incidents occurred in the last 24 hours. Consideration is given to whether the air traffic services (ATS) system was potentially causal or contributory in those incidents identified as pilot attributable.

Airservices notes that non-ATS-attributable LOS occurrences are subject to the investigations by aircraft operators and the ATSB which is the lead agency responsible for conducting independent investigations of safety occurrences. Whilst Airservices is committed to continuing our existing support of the ATSB's investigations, Airservices does not have the direct legal authority for investigating non-A TS-attributable LOS occurrences.

However to promote the safety of air traffic, Airservices engages in collaborative activities with industry to share safety information regarding all LOS occurrences and participate in joint investigations. Airservices has initiated a workshop with the major domestic and regional airlines to develop a protocol to enable joint Airservices I airline investigations to be conducted. This workshop is planned for 22 August 2013 in Canberra. This in effect will achieve the same outcome.

Further, Airservices conducts the annual Airline Safety Forum and hosts Heads of Safety Meetings to engage industry in discussing and evaluating the safety performance of the air traffic management network. These forums include the exchange of safety performance information and data based on errors and occurrences reported under both our and the airlines' safety management system (SMS).

They also inform the publication of our internal quarterly external threat assessment report on LOS occurrence trends, key systemic safety issues and actions for safety improvement.

In addition an action from the most recent Airline Safety Forum is underway to conduct formal hazard/risk workshops focusing on the interfaces between the air traffic and aircraft operations. This will assist in identifying opportunities to improve the management of internal and external threats (e.g. pilot attributable factors).

 

ATSB comment in response:

The ATSB acknowledges the actions already taken by Airservices Australia and future action planned. The ATSB understands that Airservices does not have legal authority to compel pilots to be involved in investigations, but has other mechanisms available to obtain information from pilots involved in loss of separation occurrences such as voluntary and confidential surveys. In addition, the ATSB believes that the safety of civil airspace in terms of aircraft separation is not fully being monitored by current processes either within Airservices or by the Civil Aviation Safety Authority which requires Airservices to regularly report trends and internal investigations of air traffic services-attributable LOS occurrences only. As such, the ATSB is issuing the following recommendation.

Recommendation

Action organisation: Civil Aviation Safety Authority
Action number: AR-2012-034-SR-016
Date: 18 October 2013
Action status: Released

The Australian Transport Safety Bureau recommends that the Civil Aviation Safety Authority, in consultation with Airservices Australia and major aircraft operators, use all available information to assure the safety of civilian airspace through actively monitoring and investigating loss of separation incidents attributable to pilot actions in addition to the current focus on air traffic services-attributable occurrences.

ATSB response:

The ATSB acknowledges that as Australia’s independent transport safety investigation agency, it has a role to investigate serious incidents, including serious LOS incidents resulting from pilot actions. Such investigations provide an opportunity to learn from others’ errors and correct any system issue identified, both in the ATS environment and in the aircraft operation environment.

Therefore, the ATSB is committed to undertaking investigations into all LOS occurrences classified as serious incidents, including those that appear to be a result only of pilot actions.

Correspondence

Date received: 08 January 2014
Response from: Civil Aviation Safety Authority
Action status: Closed
Response text:

I accept this recommendation and CASA will address the issue. CASA currently monitors and reviews safety occurrence data, including reported Loss of Separation (LOS) incidents, to determine whether a potential safety issue exists or there has been a regulatory breach.

This process is described in the CASA Surveillance Manual. Occurrences are assessed to determine their criticality, and appropriate follow-up investigative actions are determined with regard to a number of factors. Some information can be, and often is, obtained through consultation with Airservices Australia and from internal investigations conducted by aircraft operators. CASA will ensure that every reported LOS incident is assessed, and where considered to be potentially attributable to pilot actions, will conduct further investigations in relation to potential safety issues or regulatory breaches and record the outcomes.

I acknowledge that there will be a meeting on 14 January 2014 between the ATSB, CASA and Airservices to further explore this safety recommendation. Depending on the outcome of this meeting this response may be updated to reflect any agreed action as appropriate.

ATSB response:

The ATSB welcomes CASA’s commitment to address all aspects of the identified safety issue through the monitoring of pilot-attributable loss of separation incidents and investigation outcomes of these incidents.

Since this response, the ATSB has met with CASA and Airservices Australia to discuss practical solutions to address the safety issue. It was agreed that it would take a combined effort between airlines, Airservices Australia, and CASA. To help clarify the safety issue, the owner of the safety issue has been changed from Airservices to CASA. The safety recommendation has also been recast to improve the clarity of the expected actions to assist CASA in achieving a practical and on-going solution to:

The Australian Transport Safety Bureau recommends that the Civil Aviation Safety Authority, in consultation with Airservices Australia and major passenger aircraft operators, should ensure the use all available information to assure the safety of civilian airspace through actively monitoring and the gathering of information concerning contributing factors for loss of separation incidents attributable to pilot actions in addition to the current focus on air traffic services-attributable occurrences.

Date received: 15 April 2014
Response from: Civil Aviation Safety Authority
Action status: Monitor
Response text:
CASA acknowledges (a) that the ATSB has changed the owner of this safety issue from Airservices Australia to CASA, and (b) the revised wording of the safety recommendation. I accept this safety recommendation and CASA will address the issue.
CASA currently monitors and reviews safety occurrence data, including reported Loss of Separation (LOS) incidents, to determine whether a potential safety issue exists or there has been a regulatory breach.

This process is described in the CASA Surveillance Manual. Occurrences are assessed to determine their criticality, and appropriate follow-up investigative actions are determined with regard to a number of factors. Some information can be, and often is, obtained through consultation with Airservices Australia and from internal investigations conducted by aircraft
operators.

CASA will assess every reported LOS event involving or related to a Regular Public Transport aircraft. If that assessment indicates the event was caused by pilot error, CASA will conduct further investigations into the event and record the outcomes of that investigation.
Date received: 19 September 2014
Response from: Civil Aviation Safety Authority
Action status: Closed
Response text:
CASA has now issued a Management Instruction on 14 August TMI-2014-003.

The purpose of this TMI is to provide notification and direction to all CASA Divisions that, effective from 8th August 2014, all controlling offices are to assess all LOS events involving or related to an RPT aircraft. If that assessment indicates the event was caused by pilot error, CASA will conduct further investigations into the event and record the outcomes of that investigation.
   
Current issue status: Adequately addressed
Status justification:
The Civil Aviation Safety Authority has committed to routinely assessing all loss of separation occurrences relating to regular public transport (RPT) aircraft and will conduct and record investigations into the those occurrences that are pilot-attributable.
 
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Last update 19 September 2014