Recommendation R20040014

Recommendation issued to: AirServices Australia

Recommendation details
Output No: R20040014
Date issued: 15 January 2004
Safety action status:
Background: Why this Recommendation was developed

Output text

Safety Recommendation

The ATSB recommends that Airservices Australia, in consultation with the Civil Aviation Safety Authority and the NAS Implementation Group, review NAS procedures and communications requirements for operations in Class E airspace, with particular emphasis on air transport operations during climb and descent in non-radar airspace, with a view to enhancing situational awareness of pilots operating in that airspace. The review should include examination of, and where necessary revision and updating of, education, training and chart frequency material.

Initial response
Date issued: 20 February 2004
Response from: AirServices Australia
Action status: Monitor
Response text:

Airservices Australia has conducted a review of all of the issues related to the Launceston incident including those issues specifically sighted in the ATSB recommendation. The observations, initiatives and recommendations listed below have been fully discussed with CASA and the NASIG, and we are currently working to ensure implementation is properly coordinated.

As a part of our normal risk monitoring processes, reports from electronically submitted incident and event reports are continuously reviewed. The information, available up until 17 February 2004 indicates that 60 (6.5%) of all reported incidents (915) can be assessed as relating to the changes made on 27 November 2003. Of these 60 incidents 81.6% are pilot attributable with the main factors either being pilots failing to comply with the new changes or violating controlled airspace. This data has shown that pilot education and training has not been as effective as it was expected to be.

The ATSB Report also highlighted a possible misunderstanding by pilots of the intent of the pilot education and training.

Airservices proposes the following strategies to address the issues concerning pilot education and training:

(a) That CASA conduct a quality assurance assessment of the pilot training and education as well as pilot comprehension of the material. Confirmation that pilots correctly understand the published material, especially the general aviation segment, is important to the safe operation of the airways system; and
(b) That further pilot education be developed with a particular re-emphasis on requiring pilots to:
(i) Monitor the most appropriate frequency to assist in situational awareness;
(ii) Make radio contact with flights considered to be in potential conflict to assist in situational awareness;
(iii) Comply with the need for transponder carriage, use serviceability; and
(iv) Recognise that the more flexible procedures and airspace introduced on 27 November 2003 places additional responsibility on pilots and that the ongoing safety of the system requires that they comply and understand the requirements which permit this additional flexibility. CASA was advised of these pilot training and education strategies on 16 January 2004, and subject to their agreement, CASA would be responsible for implementation.

The review of incident data and the ATSB Report also raised an issue of pilot situational awareness, especially within Class E airspace. Transponder non-usage and/or unserviceability has also been a noticeable trend and can be associated with the situational awareness issue. Immediate strategies that address this issue are as follows:

(a) To assist pilots to choose the most appropriate frequency and assist them in gaining situational awareness, a frequency planning chart will be published depicting enroute frequencies in Class G and Class E airspace. This is an interim chart until the normal charting cycle takes affect and will be published and distributed within the next month.
(b) That information be issued to air traffic controllers reiterating the importance of their radio broadcasts as these broadcasts also provide situational awareness to aircraft. This information has been published and took effect on 1.9 January 2004.
(c) That procedures be developed and promulgated that require pilots, that have unserviceable transponders, to have them repaired as soon as practicable following notification by ATC of unserviceability. Again this strategy will require agreement with and subsequent implementation by CASA.
Further work is also continuing on rectifying a design issue with the control area steps to the north east of Launceston. The current design can contribute to a steeper than normal descent profile.

CASA were advised of these further strategies on 16 January 2004.

The NASIG were advised of all of the above mentioned strategies at a meeting held on 23 January 2004 and again at a meeting with the NASIG and [name deleted by ATSB], of DOTARS, on 19 February 2004.
These strategies will be implemented as soon as practicable with consultation and agreement, where necessary, with the relevant agencies.

Further correspondence
Date issued: 28 June 2007
Response from: AirServices Australia
Response status: Closed - Accepted
Response text:

Airservices Australia advised that pilot education material was distributed as part of the NAS 2c changes implemented 24 November 2005. Also, AIP charts were amended to include additional frequency information to assist pilots to monitor the Class E radio frequency.

Last update 01 April 2011