Recommendation R20040062

Recommendation issued to: AirServices Australia

Recommendation details
Output No: R20040062
Date issued: 07 June 2004
Safety action status:

Output text

Safety Recommendation

The Australian Transport Safety Bureau recommends that Airservices Australia review the effectiveness of its check and training program in the area of procedural control services.

Initial response
Date issued: 23 July 2004
Response from: AirServices Australia
Action status: Open
Response text:

Currently Airservices can see no justification to support this recommendation if it is based on the single incident referred to in the brief. The individual involved was checked following the incident and returned to duty. It should also be noted, as referenced in the report, refresher training for all tower controllers has been provided in radio telephony in regard to visual separation which was an error in the incident.

ATSB response:

Your response to the recommendation R20040063 is accepted by the ATSB and its status will remain classified as "MONITOR" until the MATS amendment has been incorporated.

Your response to the recommendation R20040062 however, is not accepted by the ATSB and its status remains classified as "OPEN". While your response meets the literal interpretation of our recommendation, I am concerned that the focus of your response was on visual separation. The ATSB recommendation was made because the controller did not provide any form of procedural separation between the two aircraft prior to the application of visual separation. Indeed, the investigation has discovered that there may be a more widespread problem within Airservices Australia of a limited understanding of procedural separation concepts.

The Secretary of DOTARS has noted that if there are systemic problems, they must be clearly identified and fully addressed. The ATSB recommendation was not based on a single incident and OASIS summaries of other incidents where procedural separation standards have not been applied are attached at Enclosure 1. Accordingly, you are encouraged to undertake a broader review of the effectiveness of Airservices Australia's check and training program in the area of procedural control services.

Further correspondence
Date issued: 10 December 2004
Response from: AirServices Australia
Response status: Closed - Partially Accepted
Response text:

I write in response to a letter from (name deleted) which was dated the 18th of August 2004. This letter indicated that our previous response to recommendation R20020062 was not accepted by the ATSB as it was believed that Airservices Australia had taken the literal interpretation of the recommendation and had focused on visual separation. The letter suggested on the basis of a list of incidents provided that Airservices Australia take a broader review of the effectiveness of Airservices Australia's check and training program in the area of procedural control services.

Following receipt of this letter, (name and position deleted) undertook a review of the occurrences provided (see commentary provided at Appendix A). This review compliments the analysis completed for the Breakdown of Separation (BoS) Review which was conducted in 2003, and the post-implementation review of the associated BoS Recommendation project which also evaluated incidents from a controller performance stand point. In neither review did Airservices Australia identify unhealthy norms or systemic performance issues within the procedural Tower environments. These reviews conclude that Airport Services conducts performance checks in accordance with the requirements of the CATSOAM.

The mandated CATSOAM checking regime is complimented by the Cross Unit Evaluations which are conducted on an annual basis within Airport Services. This program demands that a selected ATC from a like type tower (eg GAAP, regional, radar) evaluate the operations at another Tower. The Tower Manager and one other controller are checked by the visiting ATC to ensure that the standard of checking is maintained at the highest level. A full and comprehensive report is supplied after each of these station checks.

Each year like type tower conferences are held [GAAP, Regional and RADAR] and all aspects of check and training are raised in the forum.

As recognised in your letter, one of the most difficult aspects of Regional Tower Control is the concept of procedural separation and its application in the different classes of airspace and different categories of aircraft. The number of ATC's that fail to achieve rating standard in our regional ports is testimony to the importance of this concept being fully understood.

The training for rating and subsequent checks to maintain ratings, is intensive and exhaustive, and we remain convinced that we do not have a systemic problem with our checking regime for procedural towers.

Appendix A

Hamilton Island 25/5/1999
No separation standard was applied.

Argyle WA 19/3/2001
Not a Tower issue.

Tamworth 27/6/2001
This is not a procedural separation issue for the tower as such. The aircraft was on a visual approach entering the circuit and failed to join final as instructed resulting in the aircraft flying through final. The controller was not required to apply a procedural standard as he was using visual separation at the time. This occurrence is a failure on the pilot in command to comply with procedures.

Albury 8/7/2002
In this breakdown, the understanding of the procedural separation requirement is quite clear. The phraseology was poor.

Mackay 16/11/2002
Separation Standard was not applied.

Mackay 29/1/2004
Separation Standard was technically infringed as the ATC used TSAD to establish one aircraft OCTA. The ATC fully understood the procedural standard.

Hamilton Is 17/7/04
A procedural standard had been established between the aircraft. Misunderstanding of circuit entry direction then led to a breakdown in separation.

Last update 01 April 2011