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What happened

At 1253 Central Standard Time on 27 February 2014, a Boeing Company 737-8FE, registered VH-VOM (VOM), was radar vectored when outside controlled airspace, near Darwin, Northern Territory. Radar vectoring outside controlled airspace was not permitted, and may have brought VOM into conflict with aircraft that were unknown to air traffic control.

What the ATSB found

The ATSB found that weather in the Darwin area resulted in the majority of inbound aircraft diverting around storm cells. These diversions increased workload for the Approach East controller. The increased workload resulted in the controller using non-standard phraseology and not cancelling radar vectors prior to VOM leaving controlled airspace. Additionally, the flight crew of VOM had not reported ‘clear of weather’ as expected by the controller. This resulted in a lack of shared understanding between the flight crew and the controller.

What's been done as a result

Following this occurrence the Department of Defence introduced theoretical and simulator-based training to assist air traffic controllers to resolve unusual situations using clear communication and direction. The training reinforces positive and assertive control measures, skills that are especially necessary in high workload situations.

Safety message

This occurrence highlights that effective communication is essential for a shared understanding between flight crew and air traffic controllers. On this occasion, the use of non-standard phraseology by both parties resulted in different expectations and delay. Additionally, coordination between controllers is an essential component of their duties; however, this is not transmitted via radio. As a result, silence on an air traffic control frequency should not be interpreted by flight crew as an indicator of low workload for the controller.

Download Final Report
[ Download PDF: 988KB]
 
 
 

The occurrence

Context

Safety analysis

Findings

Sources and submissions

 
General details
Date: 27 February 2014 Investigation status: Completed 
Time: 12:50 CST Investigation type: Occurrence Investigation 
Location   (show map):near Darwin Airport Occurrence type:ANSP operational error 
State: Northern Territory Occurrence class: Airspace 
Release date: 15 April 2016 Occurrence category: Incident 
Report status: Final Highest injury level: None 
 
Aircraft details
Aircraft manufacturer: The Boeing Company 
Aircraft model: 737 
Aircraft registration: VH-VOM 
Serial number: 33794 
Operator: Virgin Australia 
Type of operation: Air Transport High Capacity 
Sector: Jet 
Damage to aircraft: Nil 
Departure point:Sydney, NSW
Destination:Darwin, NT
 
 
 
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Last update 15 April 2016