Recommendation R19980156

Recommendation issued to: AirServices Australia

Recommendation details
Output No: R19980156
Date issued: 18 August 1998
Safety action status:

See report B98/90 - `Systemic Investigation into factors underlying air safety occurrences in the Sydney Terminal Area airspace'.

Output text

The Bureau of Air Safety Investigation recommends that Airservices Australia review its change management procedures and the program for change leading up the Olympics. The review should ensure that safety is not compromised to meet project schedules or perecieved community imperatives.

Initial response
Date issued: 19 September 1998
Response from: AirServices Australia
Action status: Open
Response text:

I refer to your letter of 14 August 1998 concerning the Bureau of Air Safety Investigation (BASI) report on operations in the Sydney terminal airspace area (Investigation Report B98/90).

The report was initially considered by the Board Safety and Environment Committee on 14 August 1998, the day the report was formally issued by Government. Subsequently, the BASI report was considered at the full Board Meeting, held on 21 August 1998.

The Board and Management of Airservices are affording priority consideration to the BASI recommendations and findings. We will work closely with the Civil Aviation Safety Authority in assessing the actions necessary to address the recommendations and findings of the BASI report.

I will write again shortly, when the specific action plans are developed.

Further correspondence
Date issued: 13 November 1998
Response from: AirServices Australia
Response status: Monitor
Response text:

Airservices Australia continuously monitors the introduction of new procedures and processes to ensure that the operational impact of that change is well managed. Whilst acknowledging this recommendation it must be recognised that, from time to time, changes to procedures will be necessary.

The program of change in Sydney has been extensively reviewed with changes prioritised to ensure that safety is not compromised whilst maintaining an implementation schedule. For example: training for TAAATS transition has been postponed until March 1999 and the Sydney Long Term Operating Plan (ELTOP) Mode 8 has been deferred until mid 1999 whilst Mode 6A has been deferred until late 1999.

ATSB comment:

The Bureau responded on 4 January 1999 as follows:

The Bureau does not consider that this response adequately addresses the recommendation. The delay of the introduction to some of the proposed changes to Sydney terminal area procedures may be manifestations too the adjustments of the previous change management process. However, no information has been provide to explain how Airservices "reviewed" the change management procedures in place at the time of the report, nor was any information provided about what processes and mechanisms are now in place to ensure that the change management process is sufficiently robust to detect safety deficiencies and ensure that safety is not compromised in the future.

Further correspondence
Date issued: 19 July 1999
Response from: AirServices Australia
Response status: Closed - Accepted
Response text:

I am writing to provide a response to the BASI Systemic Review of Airservices' operations at Sydney Airport and subsequent investigations which have resulted in recommendations correlated with that review.

Airservices has previously responded to the following recommendations and has been advised that BASI has accepted those responses and closed off any further action:


The following is a precis of the action Airservices is undertaking in response to the remaining outstanding recommendations:


Airservices Australia review its change management procedures and the program for change leading up to the Olympics. The review should ensure that safety is not compromised to meet project schedules or perceived community imperatives."

The agenda for change is set during the business planning cycle and updated as operational requirements change. To increase the integrity of the change process a new management structure has been established, which includes a Quality Manager. Safety initiatives undertaken include the:

- establishment of a Safety Panel whose major task is to review and direct action on recommendations,
- conduct of structured safety management training approved by the Directorate of Safety and Standards,
- development of a new "Request for Change" process which is more user friendly, and has a clearer structured sign-off process,
- flow of information on changes to our staff through promulgation of Team Briefs to staff by Sydney Operations Management Team and more structured Team Days.
- plan of action to give access to all staff of the Local and Temporary and Management Instructions through the Airservices AVNET.
- establishment of Safety Cases and Post Implementation Reviews whose outcomes will be reflected in the "Request for Change" process.

ATSB comment:

The Bureau wrote to Airservices Australia on 17 December 1999 stating that the Bureau had classified the latest Airservices response as CLOSED-ACCEPTED but that the Bureau would monitor the implementation and effect of the initiatives outlined in that response.

Last update 01 April 2011