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Aviation

Systemic investigation of air miss occurrences 1991-1992

Summary

The Australian Air Traffic Service (ATS) system provided by the Civil Aviation Authority (CAA) is responsible for the provision of a safe, efficient, and cost
effective air traffic control and advisory service to the aviation industry within domestic and international (oceanic) airspace.

This BASI study conducted during 1992 was aimed at understanding the organisational factors and system characteristics, and the underlying failures
which lead to certain ATS occurrences. BASI's endeavour was to provide the CAA with a method which would allow the cause of a particular problem to be
tracked to its origin. Thus potential remedial action could be applied at the source of the problem.