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Recommendation issued to: AirServices Australia

Recommendation details
Output No: R19990220
Date issued: 19 January 2000
Safety action status:
Background:

SUBJECT - MANAGEMENT OF FLIGHT SERVICE


SAFETY DEFICIENCY

Human factor issues in flight service centres are creating an environment in which safety may be compromised.


FACTUAL INFORMATION

As a result of several occurrences, including the above occurrence (199900266), the Australian Transport Safety Bureau, formerly the Bureau of Air Safety Investigation, issued Safety Advisory Notice (SAN) 19990055 to Airservices Australia on 29 July 1999. The SAN was released to the public on 5 August 1999. The safety action in the SAN suggested that "Airservices Australia should note the safety deficiencies detailed in this document and take appropriate action". While Airservices Australia advised the Bureau of receipt of the SAN, it did not provide a formal response, nor was a response required.

The Bureau has continued to monitor reported incidents for "failure to pass traffic" and "failure to coordinate" that were considered attributable to flight service. This monitoring revealed that for the period 1 January 1999 to 1 December 1999 throughout Australia, there were 21 occurrences of "failure to pass traffic" and 6 occurrences of "failure to coordinate".

Of concern is the increasing trend for "failure to pass traffic" occurrences in the Sydney, Melbourne and Brisbane flight services centres. In 1995 there were 4 occurrences, 1996 - 6 occurrences, 1997 - 6 occurrences, 1998 - 8 occurrences, and in 1999 - there were 17 occurrences.

As reported in the SAN, human factors issues in flight service centres are considered to be creating an environment where safety may be compromised. These issues include, but are not limited to, low morale, increased stress, increased workload, inadequate supervision, inadequate rostering, fatigue and inadequate resources. Airservices Australia's Safety Cell in Brisbane highlighted these issues in an internal report prepared in July 1999. The report was forwarded to the Bureau on 28 October 1999. The Bureau has also received advice that a Melbourne flight service centre audit had similar findings.


Recent Occurrences

Summary of Occurrence 199904539 (ESIR 1999 02936 BCO)

The crew of VH-CCJ climbed to flight level (FL) 150 from FL140 to avoid VH-TUZ, which was on a crossing track at FL140. Both aircraft were operating under the instrument flight rules (IFR). Consequently, the flight service (FS) officer was required to provide traffic information to the crews, but did not do so.

The investigation found that immediately prior to the occurrence, the FS5 air/ground operator became increasingly busy and, after CCJ had reported at Kidston, that officer requested, and was provided, the assistance of a coordinator. Multiple coordination tasks were effected. CCJ was coordinated with FS1, however the transfer time was incorrectly calculated and coordinated. The FS1 air/ground operator did not notice the incorrect transfer time. The FS1 was distracted by other events that were occurring and deferred providing traffic information. This decision was made because the FS1 believed that there was adequate time to re-assess the traffic situation when CCJ was in his airspace. The crew of CCJ was alerted to potential conflicting traffic on the aircraft's traffic alerting and collision avoidance system (TCAS).


Local safety action following occurrence 199904539

Airservices Australia also investigated the incident. Their report, dated 27 September 1999, recommended changes to the roster to provide additional staff coverage, revised procedures for the conduct of performance checks on flight service officers and workstation modification to allow better visibility of the FS5 position from the operational control authority (OCA) position. Workstation modification is expected in January 2000 following the submission of a "Request for Change". The implementation of the other recommendations was completed prior to 8 October 1999.


Summary of Occurrence 199904978 (ESIR 1999 03101 BCO)

The pilot-in-command of VH-KTJ sighted VH-SKZ pass 100 ft above his aircraft. Both aircraft were IFR category and the flight service officer was required to provide the crews with traffic information. Neither crew was issued with traffic information regarding each other's aircraft by flight service.

The investigation found that when SKZ taxied at York Island for Cairns, the flight service officer assessed the traffic situation. The officer relied on his memory of the proximity of the planned tracks of SKZ and KTJ, rather than refer to his overhead chart. As a result, the flight service officer made an incorrect assessment and discounted the two aircraft as traffic.

The flight service officer reported that he may have been fatigued due to insufficient sleep. Due to staff shortages the officer had not had a 2-day break from the workplace in the previous 3-week period. The officer may also have been distracted from his primary task by the need for constant manipulation of the sensitivity controls of the high frequency (HF) radio due to poor HF conditions.


Local safety action following occurrence 199904978

The Airservices Australia investigation dated 11 October 1999 recommended that the group leader obtain ratings for the specialty area to provide a degree of "insurance against staff being asked to give up too many days off in their roster". The group leader was rated in December 1999 and subsequently was able to provide additional coverage on the roster.



ANALYSIS

While Airservices Australia acknowledged receipt of the SAN 19990055 dated 29 July 1999, there is no evidence that appropriate action has been taken to address the concerns raised. Local management has responded to individual incidents by conducting investigations and has actioned some of the recommendations made for local change. However, a strategic approach by Airservices Australia is considered necessary to address the identified systemic safety issues.

The increasing trend of "failure to pass traffic" occurrences involves high-capacity fare-paying passenger transport operations. The government regards the safety of fare-paying passengers as a high priority. While a risk analysis may indicate that the chance of a mid-air collision is relatively low, failure to address these concerns within the flight service area of responsibility must increase that level of risk.

Output text

The Australian Transport Safety Bureau (formerly BASI) recommends that Airservices Australia address flight service related issues that have the potential to seriously compromise safety, including those relating to incidents where there was a "failure to pass traffic" or a "failure to coordinate".

Initial response
Date issued: 28 February 2000
Response from: AirServices Australia
Action status: Open
Response text:

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.


HISTORY

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 public.

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 issues".

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 traffic" incidents.

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 are
(Airservices data)

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 resources.

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.

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 those issues.

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 been compromised.

ATSB response:

The following correspondence was forwarded to Airservices Australia on 17 March 2000.

I refer to your letter to (ATSB officer) of 28 February 2000 concerning Recommendation R199900220.

In accordance with established practices, each of the points made in your letter has been examined against the information used to develop the recommendation. We accept that there are differences in interpretation of the "facts" and that the statistical data is not necessarily compelling of itself. However, the potential consequences of the incidents are significant. It is clear that the intent of the recommendation, to raise the profile of the safety issues in flight services centres, has now been achieved.

As recently discussed by (ATSB officer) with you in relation to another failure to provide traffic information, the actions taken by Airservices are reflected in the description of local safety action in the Occurrence Brief:

"Airservices Australia advised the ATSB that the existing flight service operations will continue until early 2001 when the nation program of incorporating directed traffic information into TAAATS will be completed. Airservices is aware of the need to be vigilant in the management of this change process."

A copy of the Occurrence Brief 199903790 is attached for your consideration prior to its release for interest party comment.

In view of the developments, you may wish to advise whether Airservices' rejection of the recommendation stands.

Further correspondence
Date issued: 30 March 2000
Response from: AirServices Australia
Response status: Closed - Not Accepted
Response text:

I refer to your letter of 17 March 2000 concerning ATSB recommendation R19990220.

I would be interested to know which "facts" you believe the ATSB and Airservices have interpreted differently? The only "facts" presented were the number of incidents, and on this matter we are in agreement.

Your statement that the "statistical data is not compelling of itself" is a gross understatement. The comparative number and spread of incidents sighted provides no statistical basis whatsoever for the conclusions drawn by the ATSB. Pressing home your argument by stating "However, the potential consequences of the incidents are significant" simply indicates a lack of understanding of contemporary risk management practice.

The potential worst case consequences for some of these incidents are significant. However, the events themselves prove that the most likely consequences of most of the incidents are not significant. Also, the relative frequency of these incidents is so low as to be almost immeasurable. Contemporary risk management is not only based on consequence, but also relative frequency. In most cases, for a risk that does not have an immediate outcome (i.e an incident rather than an accident) to be considered intolerable, it must not only have significant consequences, but also moderate or high relative frequency.

The number of flight service incidents has not changed over the last 5 years and is still so low that is practically immeasurable.

If the ATSBs position is that likely consequence and relative frequency are not generally important then almost all incidents should elicit an ATSB safety recommendation as the potential worse case scenario for most incidents are significant.

The last sentence of the second paragraph of your letter is self-serving and incorrect. The awareness of potential safety issues within flight service was always high. R19990220 has not raised the profile of the safety issues in flight services centres at all. Unfortunately, what it has done is seriously erode the ATSBs professional credibility within Airservices. Airservices is still of the view that the flight service case presented by the ATSB is flawed and does not support the conclusions or the recommendation.

In response to the local safety action statement included in Occurrence Brief 199903790, I did not have the opportunity to read it before it was released to the public. In essence, the statement is correct, but could be misleading. Stating that "existing flight service operations will continue until early 2001" could be interpreted as meaning that there will be no change to flight service operations until early 2001.

As you would now be aware, except for a small pocket of air space around Canberra and Sydney, flight service has been removed from the entire east coast of Australia. The Sydney Canberra flight service function will be removed by the end of April and the majority of the remaining non "J curve" flight service function will be discontinued by June. The last traditional flight service function will operate in Western Australia with a total of 20 to 30 officers until approximately January 2001.

With respect to the last sentence in your letter, and based on the arguments contained in my letter to (ATSB officer) of 28 February, 2000, I confirm that Airservices formal rejection of recommendation 19990220 stands.

 
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Last update 01 April 2011