Breakdown of co-ordination involving a Boeing 747-400, VR-HIE, 148 km south-east of Townsville Aerodrome, Queensland, on 17 July 1994

When the AFTN strip was made up from the aircraft's flight plan, the flight data officer did not designate the route by inserting the correct address code. When another flight data officer came to transmit the AFTN message he noted that the address code was missing. Instead of checking the flight plan he apparently made a best guess using the departure and destination aerodrome information. However, he guessed the wrong route. Consequently, some of the addressees were omitted, including the Townsville arrival's position. When the B747 departed from Brisbane, a departure message was also not sent to the Townsville arrival's controller.

When the aircraft came within the sector seven controller's jurisdiction he omitted to annotate his flight strip with the updated estimated time of arrival for the aircraft. This mistake was not recognised and coordination for the aircraft with the Townsville arrival's controller was not accomplished. The omission was not noted until the Townsville arrival's controller asked about an unknown aircraft entering his airspace from the south-east. The B747 had been maintaining 31,000 ft and there were no conflictions with other aircraft.

The sector was busy at the time with congested traffic in the Mackay/Whitsunday area which included an international aircraft with radio communications problems and unnotified light aircraft traffic asking for clearances at the new airspace boundaries in the Mackay area. While all the controller's attention was focused on this area, the high altitude B747 was overlooked.

The radar and procedural sector seven consoles were manned with a trainer and trainee at each console. The radar controller was undergoing a final check before being rated on the position. The radar console also suffered from some ergonomics deficiencies. The coordination intercom line was not operating, and the hand operated radio transmission switch was unserviceable. The radar operator had to lean across the procedural console to use its coordination line. The training was also a distracting factor because of trainer/student interaction and as a result the controllers had less opportunity to monitor each other.

The procedural console was manned by a trainee and trainer who had not operated together before. The trainee was being shown a method of laying out his flight strips which involved an altitude ranking rather than a chronological order as previously used by the trainee and his full-time instructor. This disrupted his scanning technique.

The complex combination of factors resulted in a lack of coordination between the various air traffic service units responsible for the supervision of the B747 flight.