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.