Airservices isn't and has never been a GBE. The Board's governance described it as a legislated corporation (if memory serves correct).
Practically speaking, not too much different from a GBE but the Board has restrictions as to how far they can venture from the core business'. Good intent when formed, but probably hasn't made any difference when it comes to management ineptitude.
Fair cop, pretty fine distinction though. The fact remains that ASA exists to turn a profit for the government, regardless of the "safety" and "service" veneer.
Love to hear their definition of 'core business'....
Another BOS event investigated by the ATSB has been released:
The Australian Transport Safety Bureau (ATSB) established that the controller's mental model for separation correctly identified the situation and included a plan to manage the traffic. However, the instructions that were issued to the pilot of the G-IV contradicted that mental model in that the controller cleared the G-IV for descent through and below the level being maintained by the 737. The progression towards the BOS continued when the controller did not recognise the error during the G-IV pilot's read-back of the clearance. Ultimately, the controller's earlier correct level input into The Australian Advanced Air Traffic System allowed a system alerting function to activate. In response to that alert, the controller initiated compromised separation recovery actions to recover the required separation standard. The ATSB identified a number of human factors and individual work processes that contributed to the occurrence. In addition, a safety issue was identified in respect of differences in the traffic alert phraseology between the Manual of Air Traffic Services and Aeronautical Information Publication (AIP). These differences increased the risk of non-standard advice being provided to pilots by controllers during compromised separation recoveries. In response to this safety issue, Airservices Australia (Airservices) amended the AIP to enhance understanding of the criticality of any safety alerts and avoiding actions being provided to flight crew. This amendment came into effect on 28 June 12.
Now - SAFETY ALERT, TRAFFIC IS ..., TURN LEFT/RIGHT HEADING ... IMMEDIATELY AVOIDING ACTION
PS "Air traffic officer had mental problem..." is misleading and sensationalised enough to make a tabloid proud.
ETA, interesting but overlooked element from the report,
Airservices National ATS Procedures Manual (NAPM) states that:18 A CLAM is a high priority alert and on receipt of the alert a controller must assess the integrity of the alert and shall ensure that separation is maintained if the alert is valid.
So its a high priority alert, and the first response is to assess its validity
Last edited by Nautilus Blue; 31st Jul 2012 at 07:53.
So its a high priority alert, and the first response is to assess its validity
That's because there are a number reasons it can be triggered, not just a level bust. At the edge of radar coverage levels can jump, aircraft in close proximity can cause garbling of the transponder returns and even swap levels, and sometimes a glitch just happens. If we clear you "when ready" it will go off after a while because you haven't vacated.
There are serious issues of professional and managerial competency in Airservices. They are being addressed in part by a broader study by the ATSB ordered by the Minister for Transport, Anthony Albanese, in February, and various changes in command in the air navigation services provider.
"Metron Aviation Appoints Greg Russell as Executive Aviation Advisor
Dulles, Virginia - August 20, 2012 - Metron Aviation, a subsidiary of Airbus Americas and member of the Airbus ProSky Alliance, is pleased to announce the appointment of Greg Russell as Executive Aviation Advisor for the Asia Pacific region. Mr. Russell joins Metron Aviation from Airservices Australia where he was Chief Executive Officer and possesses over 30 years of aviation experience in developing strategies and applying technologies to transform the performance of air transportation systems.
Mr. Russell is a recognized Air Traffic Management (ATM) and Collaborative Decision Making (CDM) visionary who spearheaded Airservices Australia's initiatives to improve air traffic efficiency and environmental performance. During Mr. Russell's tenure, Airservices positioned themselves as a world leader in the utilization of cutting-edge technology to enable real-time collaboration among airline, airport and Air Navigation Service Provider (ANSP) operations. His key programs have produced dramatic, measurable benefits for Australia's aviation stakeholders, improving flight times, lowering delays and decreasing congestion, all while reducing emissions and fuel burn. Until recently he was Vice Chair of the Civil Air Navigation Service Organisation (CANSO) and Chair of the CANSO Asia Pacific CEO Committee."
HMMMM!!! For those of you who dont know, Metron are the suppliers of the CDM equipment and software purchased by Airservices.
Mr. Russell is a recognized Air Traffic Management (ATM) and Collaborative Decision Making (CDM) visionary who spearheaded Airservices Australia's initiatives to improve air traffic efficiency and environmental performance.
Well, well, well
This is just another re-cycling trick - A bit like Bob Collins to PNG!!
I have always thought that Prof Reason's desription of aviation accidents as swiss cheese holes lining up a dangerous description, especially for training and learning purposes. It somehow implies that outcomes are naturally biased to safety, and that a long sequence of improbable events have to go pear shaped for serious events to occur.
A more helpful way to think of it is as "negative swiss cheese" - that is, that most or all critical components of a flight have been performed to a clearly safe level , for things to go " right". For significant components of the safety chain, one swiss hole may be all it takes. The other advantage of thinking about safety this way is that one day, when a really bad day comes along, the more things that routinely go "right", there is less tendency for compounding error ( ie as in AF 447) to take hold.
Also,early subtle fatigue can have a major impact on function well before self reporting occurs.
Mimpe - Also, early subtle fatigue can have a major impact on function well before self reporting occurs
Interesting point – if you take, just for debate purposes, fatigue issues as a 'stand alone' risk.
A quick nasty analysis of say two dozen trucks all heading for the same parking area, all have been on the road all night. On the open road the chances of a fatigued driver having an accident are there, but the risk levels are low scale in comparison to a high density traffic situation, say morning rush hour. If the trucks are all due to arrive at about the same time, into a radio controlled unloading area; to keep things moving smoothly, the 'controller' would need, given the circumstances, to bring an A game performance to work.
Most of the drivers are knackered and at the terminal stages of the journey start thinking about getting out, not getting there. They all, in the terminal stages become dependant on the control, relaxing as the end of a long shift approaches.
Then the deck gets stacked; 25% of the drivers have done double shifts, 10% are sick, 20% have 'home' worries, 20% have money worries and the closer to home they get, the more prominence the problems assume. If the controller has the same problems, the seeds are sown. Someone in this (half arsed) mix has to be 'on the ball'.
We tend to think of 'fatigue as a 1 man issue; what I am trying (badly) to get at is the increased risk when everyone involved is fatigued, not just one. It must increase the risk levels?
I wonder just how deeply, and how often long term fatigue affects the very few coal face controllers we have? The ATSB stats for the last 12 months are 'interesting'.
Fatigue-countering mechanisms must include science-based, data-driven hours-of-service limits, particularly for professional drivers, pilots, mechanics, and air traffic controllers.
The medical oversight system must recognize the dangers of sleep-related medical impairments, such as obstructive sleep apnea, and incorporate mechanisms for identifying and treating affected individuals.
Employers should also (1) establish science-based fatigue management systems that involve all parties (employees, management, interest groups) in developing environments to help identify the factors that cause fatigue, and (2) monitor operations to detect the presence of fatigue before it becomes a problem.
Because “powering through” fatigue is simply not an acceptable option, fatigue management systems need to allow individuals to acknowledge fatigue without jeopardizing their employment.
Last edited by Kharon; 27th Aug 2012 at 00:26.
Reason: Missed a bit
Here's an excerpt from the last round of the Senate Estimates:
Question no.: 101 Program: n/a Division/Agency: (CASA) Civil Aviation Safety Authority Topic: Air Traffic Control Proof Hansard Page/s: Written Senator Xenophon asked:
I have been developing a growing disquiet about the state of Air Traffic Control (ATC) in Australia. Not only does it seem that there is a significant increase in the number of Breakdown of Separation (BoS) and Loss of Separation (LoS) events, but I am now hearing a lot about lack of resources, compromised training, fatigue issues and a repressive management culture. The message from the coalface is that things are getting worse, not better.
While I note the CASA evidence that a holistic examination of Airservices is underway, I can’t help wondering how effective the regulatory oversight of Airservices has been up until now, should these things prove to be true.
1. Have any Safety Cases been prepared in accordance with the provisions of Chapter 6 of the Manual of Standards Part 172 – Air Traffic Services?
(a) If so, how many?
(b) If so, what do they relate to?
(c) Have they been assessed by CASA as competent examinations of the issues?
2. Does CASA consider the Airservices’ Safety Management System (SMS) to be a mature system?
3. Does CASA consider the Airservices’ Safety Management System (SMS) to be an effective system?
4. Is CASA satisfied that the operational risks related to changes in the training systems and manpower planning have been adequately assessed and appropriately mitigated?
5. Mr McCormick stated that the individuals responsible for the oversight of Airservices Australia are all previous employees of that organisation. How does CASA ensure independence in the conduct of audits of Airservices?
6. It has been suggested to me that the Training and Checking system required by CASR Part 172 and by the Manual of Standards (MOS) has been severely compromised by underresourcing, particularly in terms of operational staff. Is CASA satisfied that Airservices have the required management and resources in place to ensure that all elements of the training and checking requirements (‘from cradle to grave’) are being consistently met?
7. Mr McCormick stated that “…If there is a large turnover then we would look to see if there was any generic issue; whether there is the same issue coming up, or why people have left…”
Given its monopoly Government Business Enterprise (GBE ) type status, how do you act on any management concerns you may have – particularly since it would be virtually impossible to “ground” them?
8. We are aware from our airline standards activities that there is a substantial amount of recent material on Safety Management Systems (SMS). The Advisory Circulars (ACs) for CASR Part 172 relating to SMS and Safety Cases date back to 2005. I am advised that those ACs are particularly lacking in substance compared to similar documents in other jurisdictions. Is there any plan to modernise those ACs?
9. Are ATS SMS audits conducted against the recent ICAO Safety Management Manual framework or against the very “lite” material in the CASR Part 172 ACs?
10. Are ATS Safety Cases assessed and audited against the recent material published by the UK CAA and EuroControl or against the older material in the CASR Part 172 ACs?
11. From a safety management and organisational perspective, ATS seems very similar to an airline. While I note your rejection of my proposed amendments to the Civil Aviation Act to mandate FRMS across the broad spectrum of “safety sensitive” occupations, I am quite surprised that there is apparently no regulatory requirement for Airservices to manage operational fatigue among its controllers. Is CASA considering a regulatory change to ensure that fatigue among controllers does not become an issue?
12. Although Airservices has adopted an FRMS, is it included as part of the CASA audit schedule, given that it is not legally required?
13. If you do audit the Airservices FRMS, now or at some future time, what benchmark will you adopt?
14. Given the monopoly position of Airservices, the safety of aircraft operated in controlled airspace has a very high dependency on the safe performance of ATS. I have some questions in relation to the safety and compliance audit program for Airservices.
(a) When was the most recent audit undertaken?
(b) What were the findings in terms of the number of observations and Request for Corrective Action (RCAs)/Non-compliance Notices (NCNs)?
(c) Where there any repetitive or recurring findings?
(d) Have all relevant areas of Airservices been audited over the last 3 years?
(e) If not, over what time period?
(f) How many audits have been conducted over the last 3 years?
(g) How many observations have been issued over the last 3 years?
(h) How many RCAs/NCNs have been issued over the last 3 years?
15. What has been the strongest enforcement action taken by CASA against Airservices over the last 5 years?
16. It is a key element of CASR Part 143 “Air Traffic Services Training Providers” that the organisation must be Registered Training Organisation (RTO) within the Australian Quality Training Framework. The Australian Skills Quality Authority (ASQA) is the national regulator of the vocational education and training (VET) sector.
(a) Is CASA delegated authority from ASQA to conduct RTO audits on Airservices to ensure continuing compliance with CASR Part 143?
(b) if not, has CASA requested the ASQA to conduct an RTO audit as part of CASA’s holistic examination of Airservices?
(c) if not, why not?
(d) when was the last RTO audit conducted on Airservices by ASQA or its predecessor body?
(e) how many RTO audits have been conducted by ASQA or its predecessor body on Airservices?
1. Yes. CASA requires all Airservices Australia (Airservices) Civil Aviation Safety Regulation (CASR) Part 172 safety cases to be prepared in accordance with the provisions of Chapter 6 of the Manual of Standards Part 172.
(a) Since 2009 CASA has reviewed 11 Safety Cases.
(b) The reviewed safety cases related to the proposed implementation of Advanced Surface Movement Guidance and Control Systems, Required Navigation Performance, changes to the Australian Advanced Air Traffic System, air traffic control tower developments, and Wide Area Multilateration.
5. The substantive Executive Manager of the Airspace and Aerodromes Division that oversights Airservices was not a previous employee of Airservices.
The independence and objectivity of surveillance activities is also assured by:
• employment of experienced and suitably qualified air traffic control specialists and auditors;
• establishing controls for objectivity and independence of audits;
• audit activities generally being conducted by teams of at least 2 auditors;
• internal procedural measures are established to ensure that an exclusionary period of time, usually 2 years, is applied to any auditor who may be called upon to audit a specialist area where they were employed; and
• employment of a number of staff who have gained broad and diverse industry
experience through previous employment in other State regulators, the Australian
Defence Force Air Traffic Services and other industry organisations.
6. CASA is satisfied that Airservices has a suitably documented process covering training and checking.
7. CASA regulates Airservices’ certificates by taking appropriate regulatory action as it does with other certificate holders. The responsive options available to CASA include the imposition of conditions and issuing directions to Airservices.
8. CASA considers CASR Part 172, the associated Manual of Standards (MOS), coupled with Airservices’ approved SMS, provides sufficient substance for surveillance of Airservices’ SMS performance.
The International Civil Aviation Organization (ICAO) is developing a new Annex that will consolidate all SMS aspects currently contained in various annexes. Similarly, CASA is currently exploring the possibility of developing a new CASR part which would deal with SMS applicable to all aviation organisations, including airlines and air traffic service providers. This part would bring together the requirements for SMS for all aviation organisations and would involve a review of SMS requirements, including guidance material, for each sector of the aviation industry.
9&10. Airservices has a SMS which must comply with the MOS for CASR Part 172 and forms part of its Operations Manual. It is appropriate that Airservices’ SMS performance is audited against its SMS rather than the ICAO Safety Management Manual or against UK or European SMS guidance material.
11. CASA considers fatigue risk management integral to the operation of Airservices’ SMS and has conducted recent surveillance of the improvements to Airservices initial ATS fatigue management system and no safety issues were identified during that surveillance.
Airservices’ fatigue risk management system reflects good practice and is consistent with ICAO Standards and Recommended Practices for ATC’s.
12. CASA audits Airservices FRMS as a component of its SMS.
13. CASA adopts benchmarks that reflect improvements in global practice and which conform to the Australian aviation regulatory standard in force at that time.
14. (a) The most recent Part 172 audit was conducted at between 7-11 May 2012.
(b) CASA issued 3 Noncompliance Notices and 9 Observations.
(c) A recurring finding from this audit was that some refresher training modules did not include a suitable means and criteria of assessing satisfactory completion of the training (as required by the Airservices Operations Manual). A Non-Compliance Notice was raised in this regard.
(e) Not applicable.
(f) CASA has conducted 64 Air Traffic Services-related audits.
(g) CASA has made 104 Air Traffic Services related Observations.
(h) CASA has issued 66 Air Traffic Services-related Request for Corrective Action
(RCAs)/Non-compliance Notices (NCNs).
15. CASA has undertaken no enforcement action against Airservices in the last five years.
16. (a) CASA is not delegated authority from ASQA to conduct RTO audits on Airservices.
CASA audits Airservices compliance with the requirements of CASR Part 143. CASA has conducted significant surveillance of the Training Academy in the last three years.
(c) CASA has not identified a need for a special ASQA audit of Airservices.
(d) CASA understands that the last RTO audit conducted on Airservices took place in 2008; the current registration being valid until 31 May 2013.
(e) CASA understands that, since 2003, the year CASR Part 143 came into effect, there has been one RTO audit of Airservices as referred to in (d) above.
Senator XENOPHON: It was put to me that there was an incident on 12 February this year, when there was a two-hour break in terms of the air traffic controller, the rated person, being away from that post and another person was there but not of the same equivalent rating. I think normally under the rules it is supposed to be for 20 minutes, but the rated air traffic controller is the one
who is responsible. Would you be concerned about a two-hour break period?
Mr McCormick: Yes, I would be. We have discussed with Airservices this principle of the short break and they are proposing some amendments to the procedure which we hope will address these issues.
Senator XENOPHON: Perhaps you could take on notice that incident that was put to me about 12 February.
CASA has been advised by Airservices Australia (Airservices) that short breaks are not expected to exceed 20 minutes. Airservices conducted a review of the incident on 12 February this year and that review did not identify any evidence of a systemic problem but rather reflected on individual performance and Airservices has taken action to prevent a recurrence of the event.
Now let's get this straight here we have a mob that are known serial non-reporters, spinners of the truth and masters at the 'cover up' (although lately there's been several embarassing exposures of attempted cover ups) and Fort Fumble accept their word that all is sorted...hmm as gobbles would say "TICK TOCK"!
Gents, RTO ... well for me that means rejected take off, but in this case they're talking about Registered Training Organisation. They haven't looked at the training school etc rather than this two hour thing. Yeah! they don't want the training looked at too hard, seeing as a long gone manager stuffed that all up with new age management practises which is fancy bean counting. If you give the poor no bread, you can tell someone higher up that you saved on the food bill can't you.
Gobbledock, you ain't in Alabama! You must be here.
Management (everywhere) is like a bunch of teenagers. They know everything because their mates keep 'em abreast of the latest thing. Their parents know nothing... they're past it. It's a whole new world out there. When they cock up; their mates leave 'em and hide and their parents have to sort the mess with their money and contacts. When things are fixed, the teen struts around telling his mates, "They couldn't do nothin' too me. I wasn't scared."
Management cocks up and leaves for greener pastures and who fixes the mess? The people on the ground.
A.S.A. ---- Pretend business with pretend managers!
(Consultation is available, please see attached form; conditions apply).
1) That a suitably large paddock fenced to OH & S standards be leased.
2) That a Round up of all 'Crats be conducted and the whole mob yarded (in said paddock).
3) That the yarded 'crats be suitably equipped with (i) a Yellow Safety jacket and (ii) a large orange flag with the word "Safety" printed on it (in really big letters).
4) That a pensioner be hired to ride a push bike around the enclosure perimeter twice a day.
Operational overview) Every time the pensioner appears, the intent is that the yarded ones will stand, raise their flags, wave vigorously whilst robustly chanting "safety before profit". Thus, when the 'ride around' is complete, the yarded ones can return to limelight basking, troughing and perusing the provided scatology literature.
Operational aim) To yard the silly buggers, while humanely providing useful employment and shelter (UN policy) which will then allow the industry to get on and sort out the bloody mess left behind.
End view) Any dopey politician who even looks like opening its trap may be arbitrarily yarded for the duration of the clean up: N.B. they must provide their own flags; not made of money you know.
All those in favour say Aye.
Last edited by Kharon; 13th Oct 2012 at 21:21.
Reason: No, no more coffee, thank you Minnie.
Airservices conducted a review of the incident on 12 February this year and that review did not identify any evidence of a systemic problem but rather reflected on individual performance and Airservices has taken action to prevent a recurrence of the event.
Translation - the manager who pressured someone below then into doing something dodgy, has now made then a scapegoat. To paraphrase Sir Humphrey, Safety Management is not about managing safety, its is about the safety of managers.