Aviation safety issues and actions
Recommendation issued to: AirServices Australia
|Date issued:||01 October 1997|
|Safety action status:|
The Bureau of Air Safety Investigation recommends that
Airservices Australia conduct a comprehensive systems safety
analysis of simultaneous opposite direction parallel runway
The Bureau has made the following recommendation (R970151) to the Civil Aviation Safety Authority:
"The Bureau of Air Safety Investigation recommends that the Civil Aviation Safety Authority review the Operational Standard "Simultaneous Opposite Direction Operations" to ensure that it provides an acceptable level of safety."
|Date issued:||01 December 1997|
|Response from:||AirServices Australia|
I am writing in response to your occurrence report and the associated recommendation that Airservices "conduct a comprehensive systems safety analysis of simultaneous opposite direction parallel runway operations (SODPROPS)".
In addressing this recommendation, I commissioned a team to conduct an independent analysis of the SODPROPS procedure itself and the analysis that was conducted prior to the implementation of the procedure at Sydney Airport.
This team comprised representatives from ATS' Safety and Quality Management Branch, ATC specialists from Sydney and Brisbane. The team was assisted by expert support from CASA and the major domestic airlines.
In essence, the analysis team has produced a Safety Case (copy enclosed) addressing the safety issues identified by the original SODPROPS implementation team. This Safety Case has been augmented by a Fault Tree Analysis of the risk of failure of the SODPROPS procedure.
I must emphasise that the bulk of the analysis presented in the SODPROPS Safety Case reflects the extensive hazard analysis and risk mitigation work that was done by the implementation team prior to the implementation of SODPROPS.
Whilst it can be said that the data was not collated into a concise document (for which CASA and Airservices now advocate a Safety Case), the data was available in relevant files within the Sydney management system at the time of the BASI investigation.
The data used in this report was available in relevant files within the Sydney management system at the time of the BASI investigation.
The Fault Tree Analysis was compiled using probability data on human performance and on historical incident data.
The SODPROPS Safety Case provides the necessary assurance that SODPROPS is being operated at an acceptable level of safety.
ATSB Note: The Bureau sent an email to Airservices Australia on the 15 July 1998 asking for further information in regard to actions taken by Airservices Australia.
|Date issued:||22 September 1998|
|Response from:||AirServices Australia|
|Response status:||Closed - Accepted|
I refer to your letter of 15 July in which you sought advice of any actions Airservices Australia has taken, or intends to take, to address the issues raised by Mr [name] in his report of his review of the SODPROPS safety case.
We note that [name supplied] conducted the review on behalf of the Bureau and that the Bureau has not made recommendations arising from this review, nor do you indicate that the Bureau supports [name] findings. Nevertheless, we are grateful for the opportunity to examine the report and address issues raised.
In relation to SODPROPS, [name] principle criticism related to the hazard identification process, the risk criteria and application of risk management principles. To address this criticism, Airservices conducted a workshop in Sydney to extend the level of hazard identification and relate the results to appropriate risk criteria. This workshop was chaired by [name supplied]. In addition, Airservices commissioned [name] to provide advice on risk optimisation measures that should be considered for Sydney SODPROPS. The results of this workshop and risk optimisation advice are being developed into a Phase 2 Safety Case for SODPROPS.
In keeping with our continuing commitment to enhance our management of the safety of air navigation, we intend incorporating into our safety management manual improvements noted from [name supplied], report and subsequent workshop.