Safety Advisory Notice SAN19990055

Safety Advisory Notice issued to: Airservices Australia

Recommendation details
Output No: SAN19990055
Date issued: 29 July 1999
Safety action status: Closed
Background: Why this Safety Advisory Notice was developed


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


Related Occurrences

The crew of an instrument flight rules (IFR) category flight received a traffic and collision alert device (TCAD) warning approximately 10 NM north of Bindook and descended to avoid conflicting traffic. The crew had not received traffic information from the flight service officer about the conflicting IFR aircraft. An investigation by the Bureau found a number of issues that were of concern, and consequently monitored the situation to establish the frequency and type of ongoing occurrences involving flight service.

The crew of an IFR category flight taxiing at Mt Isa were not passed traffic information on another IFR flight inbound to Mt Isa on the same track to be used by the departing aircraft. The flight service officer was not aware of this omission until the aircraft had passed in flight.

Research Activity

A search of the Bureau's database was conducted to identify occurrences involving the failure of flight service officers to pass traffic information and coordinate traffic from 1993 through to 1997. A matrix was developed to show the number of each type of occurrence for Sydney, Brisbane and Melbourne Flight Service centres. The figures indicated that the number of occurrences for each "failure to pass traffic" and "failure to coordinate" was fairly consistent for each location.

A second search of the Bureau's database was conducted covering the periods 1 January to 1 May for both 1998 and 1999 to ascertain the number of occurrences in non-controlled airspace. This search found that the failure rate for both years was comparable for reported occurrences in an area within the responsibility of the Brisbane, Melbourne and Sydney Flight Service centres. During 1998 there were 14 occurrences, while there were 13 in 1999. The breakdown of the number of errors attributable to air traffic control and to flight service was seven each for 1998, and three and 10 respectively for 1999.

Of the three occurrences attributable to Sydney Flight Service for the 1998 period, two involved failure to coordinate errors and one a failure to pass traffic. In 1999 there were five occurrences for Sydney, all of which were due to the failure to pass traffic information.

Information on the electronically submitted incident report for occurrence 199902014 indicated that there were similar factors to that found in investigation 199900266. The factors were essentially human factor issues that indicated underlying systemic issues. They were:

1. high workload;
2. fatigue by officers due to staff shortages;
3. despondency due to impending redundancy; and
4. frustration with the work environment.

The issues were further supported by the subsequent Airservices Australia investigation, which reported that:

"1. Workload was very high.
2. Management of the staff on duty did not provide timely and sufficient support to the
air-ground officer given the disposition of traffic at the time of the occurrence.
3. Provision of the flight data contributed to the air-ground officer's distraction in strip
4. Flight crew reports may have contributed to confusion and may have given the air-ground
officer cause to assume that the traffic confliction was resolved.
5. Multiple map displays add to complexity.
6. Officer was fatigued".

The investigation report indicated that the remedial action taken consisted of:

1. the officer being suspended and undertaking 2 days of training and assessment by the team leader; and
2. other officers on duty at the time of the occurrence being cancelled.

The report did not advise of any action taken to address the systemic factors and did not contain any information under the heading "Organisational Issues". Yet the investigation report included factors that were beyond the control of the staff and consequently, were systemic in nature.

Anecdotal evidence from the flight service centres indicates issues of low morale, increased stress levels, inadequate staffing, fatigue and inadequate support mechanisms related to the ongoing uncertainty surrounding flight service operations. While industrial issues are not discounted, their existence could provide sufficient distraction to impact unfavourably upon human performance.

The apparent shift in the occurrence error type was not considered to be statistically significant but may be of concern and require monitoring to determine whether a trend develops. The constant uncertainty about the future of the flight service function is considered to be a major issue.

Systemic issues were identified by both Airservices and BASI in each of the two investigations. However, recommendations made by the Airservices investigator in investigation 199902014 did not address systemic issues that may have been adversely affecting human performance.

Output text

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

Initial response
Date issued:
Response from: AirServices Australia
Action status: Not Required
Response text:
Last update 18 March 2016