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Recommendation issued to: AirServices Australia

Recommendation details
Output No: R19980159
Date issued: 18 August 1998
Safety action status:
Background:

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 reassess the human factor hazard analysis for both Stage One and Stage Two of the LTOP safety cases so that mitigating strategies applied to identified hazards adequately allow for the fundamental limitations of human performance. In reassessing this hazard analysis, BASI recommends that Airservices Australia seek the assistance of human performance expertise.

Initial response
Date issued: 28 August 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: 16 November 1998
Response from: AirServices Australia
Response status: Monitor
Response text:

I am writing in response to the BASI report on the Investigation of Systemic Safety Issues at Sydney Airport.

The attached response provides details on Airservices ongoing actions to address the recommendations. Airservices is working closely with CASA to resolve the issues of mutual concern.

I must stress that this process is being approached with caution and planning to ensure minimal disruption to the safe and efficient operations of Sydney Airport.

Airservices will provide you with further reports on progress in due course.

R 980159 Airservices Australia reassess the human factors analysis for both Stage One and Stage Two of the LTOP Safety Cases so that the mitigating strategies applied to identified hazards adequately allows for the fundamental limitations of human performance. In reassessing this hazard analysis, BAS1 recommends that Airservices Australia seek the assistance of human performance expertise.

The LTOP Stage One and Stage Two Safety Cases have been subject to review by independent experts in the field as well as being the subject of a number of post implementation reviews. Recommendations arising from those review have been progressively evaluated and applied as appropriate.

Airservices will consider augmenting its review processes with human factors expertise in future.

ATSB response:

The following correspondence was forwarded to Airservices Australia on 4 January 1999:

R980159 - Airservices Australia reassess the human factor hazard analysis for both Stage One and Stage Two of the L TOP safety cases so that the mitigating strategies applied to identified hazards adequately allow for the fundamental limitations of human performance. In reassessing this hazard analysis, BASI recommends that Airservices Australia seek the
assistance of human performance expertise.

Response classification: OPEN

The Bureau does not consider that this response adequately addresses the recommendation. There appears to be no indication that human performance expertise has been utilised to reassess the Stage One and Stage Two LTOP safety cases. The Bureau considered that the independent assessments and the post- implementation reviews of the safety cases that had been completed at the time of the report did not include adequate human performance assessment. In addition, the response commits only to 'considering' augmenting its review process with human performance expertise. The Bureau requests that this response is reconsidered and that further explanation is provided to support Airservices position on this recommendation.

Further correspondence
Date issued: 19 July 1999
Response from: AirServices Australia
Response status: Released
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:

R980157
R980160
R980163

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

"R980159

Airservices Australia reassess the human factor hazard analysis for both Stage One and Stage Two of the L TOP safety cases so that the mitigating strategies applied to identified hazards adequately allow for the fundamental limitations of human performance. In reassessing this hazard analysis, BASI recommends that Airservices Australia seek the assistance of human performance expertise."

Airservices has engaged a Human Factors expert to carry out a study within the Sydney environment which will provide guidance and advice on the following key issues:

1. An identification of the major procedure and environmental changes in the work of Air Traffic Controllers in Sydney since March 1995.
2. In the context of the normally expected and assessed skill levels of ATCs generally:
- an assessment of the likely effects on controllers work performance brought about by the assimilation of the identified changes.
- a broad inventory of the knowledge required by individual controllers in connection with the day to day operations the current and planned implementation of the LTOP.
- advice as to the appropriateness of the current rating, endorsement and currency requirements for controllers.
- advice on the effectiveness of the training programs employed to effect the changes including any refresher programs and briefings conducted.

ATSB response:

The Bureau wrote to Airservices Australia on 17 December 1999 as follows:

The Bureau does not consider that the Airservices response adequately addresses the recommendation. Airservices is to be commended for engaging human factors expert to conduct a study of the "Sydney environment". However, that study does not appear to include a reassessment of the human factors hazard analysis for both Stage 1 and Stage 2 of the LTOP safety cases, as specifically referred to in the recommendation.

The Bureau therefore requests further advice on this matter at your earliest convenience.

Further correspondence
Date issued: 04 February 2000
Response from: AirServices Australia
Response status: Closed - Partially Accepted
Response text:

Sydney Operations has proposed a meeting with the ATSB to discuss the concerns identified in the letter. This was agreed verbally on 28 January and further contact to arrange the meeting details will follow. At your request, the ATSB Human Factors specialist will attend the meeting as it is intended that the meeting will include the consultant tasked by Airservices to address Human Factors in the Sydney environment.

ATSB response:

ATSB Note: The proposed meeting took place o the 13 April 2000. As a result of the actions agreed to, the Bureau re-classified the response.

 
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Last update 01 April 2011