ATSB recommendation R19990220 was dispatched from the ATSB to
Airservices Australia on 19 January 2000. In accordance with sub
paragraph 12.15 of the ATSB(BASI)/Airservices MOU our response to
the recommendation is due on or before 20 March 2000.
Under the heading "Factual Information" recommendation 19990220
states that the ATSB issued Safety Advisory Notice (SAN) 19990055
to Airservices on 29 July 1999.
What is not mentioned as factual information is that this issue was
originally sent to Airservices as a formal recommendation some
months earlier than July 1999. At that time I spoke to (ATSB
officer) and complained that the data and the analysis of the data
did not support the conclusions or recommendation. (ATSB officer)
reviewed the recommendation and agreed the data did not support it.
The recommendation was then withdrawn by BASI and was never made
public in that form.
The BASI investigator responsible for developing the
recommendation, (ATSB officer), subsequently spoke to both (ASA
staff member), and myself about the original recommendation. I told
(ATSB officer) exactly why I rejected the recommendation and where
I felt the data and analysis were deficient.
In July 1999 BASI raised the issue in a slightly modified form as
SAN 19990055. As the ATSB has acknowledged, SANs do not require any
formal response. However, (ATSB officer) was again given a briefing
by (ASA staff member) about the actions Airservices were taking in
response to various flight service issues.
Without any further consultation with Airservices the ATSB once
again raised the profile of the issue to that of a formal
recommendation and sent it to Airservices on 19 January 2000.
Because of an intervening long weekend, the recommendation did not
arrive at Airservices until January 25 and was not seen by me until
the morning of January 27, the day BASI made the recommendation
Had I seen the recommendation before it was made public by the
ATSB, I would have again, called into question the analysis of the
data and asked that the recommendation be withdrawn.
FACTUAL INFORMATION AND ANALYSIS
In the second paragraph of the section of the recommendation titled
"Factual Information" it is stated that in 1999 there were 6 flight
service "failure to coordinate" incidents. This is the only
reference to "failure to coordinate" incidents under the heading
"Factual Information". No other "failure to coordinate" figures are
given and no analysis is presented.
Airservices analysis of the "Failure to coordinate" data indicates
that the number of incidents Australia wide were 2 in 1995, 2 in
1996, 3 in 1997, 6 in 1998 and 6 in 1999. These sample sizes are
statistically far too small to allow any meaningful analysis, and a
figure of 6 incidents in 1999 conservatively represents less than
one one thousandth of one percent of all single IFR flights outside
controlled airspace for the year. These figures do not support the
argument that there is a trend or even a problem related to flight
service "failure to coordinate" incidents.
However, on the basis of a one year sample of six incidents, and
without any data analysis, the formal recommendation statement
requests Airservices, "address flight service issues that have the
potential to seriously compromise safety including those relating
to incidents where there was a "failure to coordinate".
Likewise, the second paragraph under "Factual Information", states
that Australia wide there were 21 "failure to pass traffic"
incidents in 1999. No where else in the document are any other
comparative figures given, or analysis provided, on an Australia
wide basis. Yet, partially on the basis of this data, and the data
referred to in the previous paragraphs, the "analysis" section of
the recommendation document states that Airservices should take a
strategic approach "to address the identified systemic safety
The data presented in the second paragraph does not support the
argument that there are any "identified systemic safety issues"
related to either "failure to coordinate" or "failure to pass
In the third paragraph under the heading "Factual Information" it
is stated "Of concern is the increasing trend for "failure to pass
traffic" occurrences in the Sydney, Melbourne and Brisbane flight
service centres." The figures are presented collectively and state
that in 1995 there were 4 occurrences, 1996, 6, in 1997, 6, 1998, 8
and in 1999 there were 17 "failure to pass traffic" incidents.
Strangely, having identified Melbourne as contributing to the
"increasing trend" in "failure to pass traffic" incidents, the list
of incidents provided by the ATSB does not mention Melbourne.
Even though the ATSB and Airservices total number of incidents
agree, the distribution of incidents does not. The reason for this
is that, the ATSB have listed the incidents by where they occurred,
rather than by, which flight services centre was involved.
Airservices have listed with respect to which centre was providing
the service at the time of the incident.
Collectively, the numbers of "failure to pass traffic" incidents
recorded by Airservices for Sydney, Melbourne and Brisbane in 1995
is 7, 1996, 10, 1997, 9, 1998, 3 and 1999, 12.
While the collective spike in 1999 is well worth closer analysis,
neither the ATSB or Airservices figures allow any meaningful
conclusion that there is any "increasing trend for "failure to pass
traffic" occurrences". This point becomes even more evident when
the figures are separated and presented independently for each of
the three centres.
Separately the "failure to pass traffic" occurrence figures
1999 1998 1997 1996 1995
SYD 6 0 3 4 4
MEL 1 1 0 3 0
BRN 5 2 6 3 3
TOT 12 3 9 10 7
To those without any formal knowledge or qualifications in
statistical analysis, an increase from 4 to 6 may look like an
increasing trend. However, in reality, none of the figures provide
any meaningful evidence to support the argument that there is an
"increasing trend" in "failure to pass traffic" occurrences
attributable to flight service in operations. Even if the ATSB
figures were used, the pattern would not change.
In the fourth paragraph under the heading "Factual Information",
the recommendation report refers to human factors issues, and two
Airservices internal reports that refer to issues such as, low
morale, increased stress, increased workload, inadequate
supervision, inadequate rostering, fatigue and inadequate
The entire thrust of both the recommendation and the supporting
information, is that, there is a direct relationship between the
number of flight service "failure to coordinate" incidents and the
"increasing trend" of failure to pass traffic incidents, and the
reported poor morale, etc, within flight service. However, as
already pointed out, there is no evidence of increasing numbers of
"failure to coordinate" or "failure to pass traffic incidents".
Further, an analysis of the 12 "failure to pass traffic" incidents
in 1999 reveals that only 2 of the incidents are attributable to
the types of issues mentioned in the Airservices internal reports.
One of the incidents was directly attributed to high workload,
while the other was attributed to high workload, fatigue due staff
shortages and despondency due impending redundancy.
The data presented does not support the argument that there is any
specific causal relationship between the group of incidents
recorded in 1999 and human factors issues, such as low morale,
within flight services.
HUMAN FACTORS ISSUES AND FLIGHT SERVICE OPERATIONS
As part of the reform of Australian airspace, a decision was made
in the late 1980s to eliminate flight service as a separate
function with some of the duties ultimately being transferred to
air traffic control. This decision clearly has employment
implications for some flight service officers.
The general morale of many flight services officers is
understandably low as many of them have been facing the possibility
of employment termination and prolonged uncertainty about when the
terminations may be enforced. As earlier demonstrated, there is no
major problem, or trend with the number of flight service
incidents, and while there is the potential, there is in fact no
direct causal relationship evident between reported poor morale
within flight service and the incidents sighted in support of the
ATSB recommendation 19990220 "recommends that Airservices Australia
address flight services related issues that have the potential to
seriously compromise safety". The recommendation implies that there
are in fact safety issues to be dealt with and that Airservices is
not addressing them.
Airservices completely rejects the ATSB assertion and is satisfied
that the flight service issues are human resources industrial
issues rather than safety issues and are being dealt with
appropriately by local and national management.
By 23 March 2000, the existing, separate flight service function
will be withdrawn from the Canberra/Ballina corridor thereby
effectively removing flight service from the entire east coast of
Australia. By mid June 2000, flight service as we know it will
cease to exist. A small number of flight service officers (20 to
30) will be retained in Perth until mid 2001 while Airservices
works towards completing the integration of directed traffic
information (DTI) into the new TAAATS environment.
SUMMARY OF RESPONSE
In accordance with sub paragraph 12.17 of the
ATSB(BASI)/Airservices MOU, Airservices Australia formally rejects
recommendation 19990220 on the basis that the analysis of the data
presented is flawed, and the recommendation directly implies that
major safety issues exist within flight service, and that
Airservices management is not taking appropriate action to resolve
The data presented in support of the recommendation does not
support the arguments that there are;
- a high number of "failure to coordinate" incidents
- an increasing trend of "failure to pass traffic" incidents
- any direct causal relationship between some existing flight
service morale issues and the data presented
- identified system safety issues.
Airservices is satisfied that the actions it is taking in response
to the various human resource issues currently existing within
flight service is appropriate and while safety issues have been,
and will continue to be monitored, the safety of operations has not