Safety Advisory Notice SAN19970137

Safety Advisory Notice issued to: Airservices Australia

Recommendation details
Output No: SAN19970137
Date issued: 27 January 1998
Safety action status: Closed

Review of Aireservices Australia's: Team Operations in Air Traffic Control and Flight Service

EXECUTIVE SUMMARY (refer to BS/960115 for full report)

A 'teams' approach to staffing was introduced to Air Traffic Services in the early 1990s by the then Civil Aviation Authority following from the recommendations of the 1987 and 1992 reviews of the Air Traffic Services System. Airservices Australia has subsequently refined the teams concept and the role of the team leader.

The teams approach has been examined by internal reviews such as the Review of Team Operations in Air Traffic Control and Flight Service (March 1992), the Teams Implementation Review (January 1994), and an as yet unpublished review which was conducted in July-August 1996.

The reviews found that some of the benefits envisioned for teams such as greater satisfaction with work schedules and improved standardisation of control techniques, were being achieved at some locations but also noted that certain difficulties were being experienced.

During 1996 and early 1997, several incidents associated with air traffic controller performance were investigated by the Bureau of Air Safety Investigation. During many of these investigations, potential safety issues associated with the operation of a teams approach were identified.

As a result of these incidents, further investigation was conducted which involved interviewing the members of the 1996 review team as well as several managers, team leaders, human resource personnel, and safety and quality management personnel.

This report contains an analysis of the further investigation and lists a series of identified deficiencies. The report contains Safety Advisory notice SAN 970137, which is addressed to Airservices Australia.

Output text

Airservices Australia should note the safety deficiencies detailed by this document and take appropriate action.

Initial response
Date issued: 30 March 1998
Response from: AirServices Australia
Response text:


Thank you for providing the report on your "Review of Airservices Australia's Team Operations in Air Traffic Control and Flight Service".

I am writing to provide comment on the report and the Safety Deficiencies identified therein.

The report is disappointing in that it generalises the issues and does not provide objective evidence to support these generalisations.

The identified Safety Deficiencies reflect this generalistic flavour and would appear to be a reflection of the author's views supported only by a select sample of incident reports.

The following commentary on the Safety Deficiencies will demonstrate my concerns: undesirably low level of operational support being provided by experienced controllers, including team leaders and other full performance controllers, to controllers working in operational positions.

The team concept, introduced as the report acknowledges, was introduced in the early 1990s to address concerns expressed in a report compiled by Dr [name supplied] in 1987.

Teams were seen as a method of providing an appropriate level of operational support and, more importantly, an ongoing mentoring capability. The previous management structure was considered inappropriate in that supervision was too far removed from the day-to-day operational workface.

The team concept has brought a level of supervision and support directly to the workface generally on a continuous basis.

The decision to require Team Leaders to perform administrative functions is a management prerogative requiring the team to be self sufficient to a certain extent. It is the Team Leader's responsibility to manage this situation whilst maintaining their own operational efficiency.

The deficiency noted that there was "an undesirably low level of operational support ..." without providing any objective evidence to either indicate what an acceptable level is or to justify such a broad generalisation.

The report states however that some of the benefits of the team concept are "co-operation between controllers, a greater degree of support from other team members, better access to management and improved standardisation".

The sample incidents quoted in the appendix provide some examples of occasions when controllers operating autonomously made errors but in those instances there is no evidence that direct supervision would have averted the situation.

ATC by its very nature is a cognitive exercise requiring much of the planning and delivery to be done by an individual. Often outside input is more a distraction than an assistance.

The examples provided in most cases do not indicate traffic levels nor just what a supervisor might have done in the instance. In other examples, controllers were actually being supervised in a check situation and the incident still occurred.

The report acknowledges that "The provision of direct supervision or monitoring on a one-to-one basis would be impractical ... "

The Team Leaders role is quite clearly to provide support and to monitor the ongoing delivery of the service to ensure its smooth running and to address the peaks and troughs in activity.

In fact the report acknowledges steps already taken to increase the support provided - "Initial indications are that these types of changes have led to an increase in the amount of operational support being provided.

On some occasions, the Team Leaders ability to always provide this level of support may be compromised by circumstances, but to over-react by increasing their presence may well prove to be counter-productive. inappropriately low level of emphasis on team development activities, such as the provision of team leader training and support, and the regular provision of team days with structured learning content for team members.

The report refers to 'a recent series of interviews" which consistently identified the lack of appropriate team leader training.

Volume 5 of the Safety & Quality Management System (S&QMS) manuals details at page 11-10 the requirements for the "Personal Development to Team Leader". This clearly states that the prospective Team Leader must "successfully complete the approved training modules for Team Leader development".

Note 3 on that page states that a person may be utilised as a Team Leader after completion of the Team Leader modules.

The revised Group structures introduced initially in Brisbane are aimed at providing a greater level of support to the operational Team Leader thus freeing up more time for them to concentrate on the support functions for their teams. This is acknowledged in the report - "Initial indications are that these types of changes have led to an increase in the amount of operational support being provided.

The statement that a lack of "the regular provision of team days with structured learning content for team members" is a safety deficiency appears to belie the statement in the report that "Most functional areas and groups now have regular team meetings in which team development activities do occur. These team meetings are very well received and provide good developmental opportunities".

Training for elements such as the introduction of TCAS and new procedures has for some time been delivered in team meeting environments.

Additionally, ATS now requires teams to conduct structured refresher training exercises during team days.

It is acknowledged that TAAATS training has impacted upon the provision of team meetings, however, the merits of providing this training far outweiqhs any negative effect.

3.performance evaluation systems for team leaders that do not ensure that relevant team leader performance areas are measured, and also do not ensure that any degradation in a team leader's proficiency on operational positions will be detected.

This is an acknowledged area of concern, in fact the whole assessment methodology for Air Traffic Controllers is the subject of a research program being conducted by the University of Queensland in co-operation with Airservices.

The intention is the all air traffic controllers within a stream, including Team Leaders, will be subject to the same scaled assessment of proficiency against identified elements of competency.

The project is scheduled for completion in 1998 and will provide a more contemporary assessment model based on validated competency requirements.

Ongoing evaluation of a Team Leader's performance or proficiency relies, on a day-to-day basis, on the Team Leader who has been selected on the basis of an extensive knowledge of the functional area. The Team Leader modules provide an awareness of the proficiency requirements and the pitfalls of inappropriate utilisation of skills.

It should be noted that the traditional checking methodology for all Air Traffic Controllers required only one "over-the-shoulder" check every six months. inappropriately low level of training and development for many controllers on human factors issues, particularly those associated with inter-controller co-ordination and communication.

This deficiency is acknowledged and is being addressed through ab initio training and in the comprehensive training package being delivered prior to transitioning to TAAATS.

The report acknowledges these measures but comments that "the extent to which this training program will increase controller's human factors knowledge cannot be determined at this stage". Surely if the effect cannot be measured the statement that the level of training is "inappropriately low, is at the very least pre-emptive.

Additionally, the claim that issues related to "inter-controller co-ordination and communication" are of concern is contrary to the statement that "inter-controller co-ordination and communication are generally performed well in many functional areas".

Whilst accepting that there are instances of deficiencies in this area demonstrated in the appendix, the safety deficiency is far too general in its implication.

The report provides information on the benefits of "Controller Resource Management" analogous with the more traditional Crew Resource Management applied by most airlines.

The benefits of this philosophy are accepted and I would say form the basis of Airservices' original decision to adopt the teams concept. The Team Leader has the responsibility to manage his resources in the most efficient and effective manner possible in any given circumstance.

The introduction of TAAATS may well "reinforce the single-operator nature of Australian air traffic control systems", however, TAAATS introduces a comprehensive array of alerting tools and prompts, not evident in the current system, to assist the operator in provision of the air traffic control.

It should be noted that many countries in the world are also looking to automation of air traffic control as the means of increasing the efficiency of the service. Associated with this there are moves towards greater autonomy in the cockpit (free flight) and less controller intervention.

Adoption of this philosophy may well result in fewer controllers and less active supervision in the future.

In conclusion, Airservices will continue to review and refine its management philosophy and the application of that philosophy.

ATSB response:

Thankyou for providing your response to Safety Advisory Notice (SAN) 970137, arising from the Bureau's review of Airservices Australia Team Operations in Air Traffic Control and Flight Services.

Your comments regarding the generalised nature of the report are noted. The Bureau would like to point out that a Safety Advisory Notice, by its very nature, may indeed be generalised, as the evidence upon which it is based may be somewhat limited or anecdotal. Alternatively, the safety impact of the safety deficiency under investigation may not, at that time, be considered to be of sufficient significance to warrant a recommendation. However, the Bureau considers that any indication of a safety deficiency present in the aviation system, cannot be ignored and must be notified to the relevant agency. Therefore, a Safety Advisory Notice is issued in order to evoke thoughtful discussion and, where appropriate, action on the part of the action agency. Under the terms of the Memorandum of Understanding between the Bureau and Airservices Australia, the Bureau does not require a formal response; however, any feedback is appreciated. It can be noted that there have been a number of instances where safety action of both a minor and sometimes significant nature, has resulted in response to Safety Advisory Notices.

Your response indicates that Airservices Australia acknowledges that there are issues of concern in relation to 'Team Operations', namely the assessment process for Air Traffic Controllers, and human factors training. It is also noted that Airservices Australia is currently taking action to address these issues and may be reviewing aspects of operational supervision. It would therefore be appreciated if the Bureau could be kept informed on the progress of the initiatives being implemented.

Last update 01 April 2011