Aviation safety issues and actions

Action related to review of GAAP operations

Issue number: AO-2008-059-SI-02
Who it affects: Pilots flying in D airspace at a capital city general aviation airport
Issue owner: Airservices Australia
Transport function: Aviation: Airspace management
Background: Investigation Report AO-2008-059
Issue release date: 31 May 2011

Safety issue description

There was no evidence of any action taken by Airservices to address safety recommendations related to a review of Key Performance Indicators (KPI’s) of GAAP operations.

Proactive Action

Action number: AO-2008-059-NSA-097
Action organisation: Airservices Australia
Date: 01 May 2011
Action status: Closed

Airservices Australia (Airservices) conducted its own investigation into the circumstances surrounding the midair collision. The Airservices investigation made the following recommendations:

Review the effectiveness of the controls for the risk of aircraft operating in close proximity to another aircraft in the air at Moorabbin. This should include but not be limited to assessment of:

  • facilities
  • traffic volume
  • staffing levels
  • hours of coverage of the Tower service
  • recommendations from reports

The ADC W position at Moorabbin should be operated as a standalone position routinely except where low workload allows it to be combined with other positions.

Include operational risk assessment of changes to local conditions for all ATC units. This should include analysis of traffic volume and any other factors that could affect complexity of operations.

Review all roving check reports for Moorabbin and ensure all recommendations have been addressed or converted to a Safety Action Improvement Report (SAIR).

Specifically, to review the closure of the recommendation to conduct a review of ...any Key Performance Indicators (KPI) affecting GAAP to ensure an appropriate balance is maintained between financial, operational and safety decision making across the organisation to ensure the action had been addressed.

Review operations at GAAP locations to identify and correct any local work practices that may have developed unchecked over time for reasons of expediency ahead of safety.

ATSB comment:

The ATSB is satisfied that the action proposed and implemented by Airservices Australia will, when complete, adequately address the safety issue.

Last update 20 February 2014