AND THE RESPONSES FROM YOUR REGULATOR:
Recommendations:
IR980253 - The Bureau of Air Safety Investigation believes that the Class G Airspace Demonstration has served its purpose. In the light of the safety concerns identified by this investigation, BASI recommends that the Civil Aviation Safety Authority should now terminate the demonstration.
The results of the demonstration should be subject to a comprehensive evaluation that specifically addresses the safety concerns identified by BASI.
The evaluation process should take into account the time required to:
- review and analyse the demonstration;
- refine the model where required and conduct a proper safety analysis; and
- provide a comprehensive and effective education and training program for any subsequent changes to Class G Airspace.
IF THIS IS NOT ACHIEVED, THE DEFICIENCIES IDENTIFIED IN THIS INVESTIGATION ARE LIKELY TO BE REPEATED, THEREBY SERIOUSLY COMPROMISING THE SUCCESSFUL INTRODUCTION OF FUTURE CHANGES TO AIRSPACE INCLUDING REINTRODUCTION OF CLASS G AIRSPACE INCORPORATING RADAR INFORMATION SERVICE AND NATIONAL ADVISORY FREQUENCY.
The Bureau of Air Safety Investigation simultaneously issues the following related interim recommendations to the Civil Aviation Safety Authority:
IR980260 - "The Bureau of Air Safety Investigation recommends that the Civil Aviation Safety Authority review program management policies and procedures for current and proposed changes to the aviation system, in the light of experience gained from the present Class G Airspace Demonstration".
IR980261 - "The Bureau of Air Safety Investigation recommends that the Civil Aviation Safety Authority, the Department of Transport and Regional Services and Airservices Australia review and clarify the roles and responsibilities of the respective organisations in relation to the regulation, design and management of airspace to ensure the safety integrity of the aviation system".
The Bureau of Air Safety Investigation simultaneously issues IR980261 to the Department of Transport and Regional Services and Airservices Australia as IR980256 and IR980257 respectively.
Responses:
This document provides CASA's responses to the safety concerns raised by the Bureau of Air Safety Investigation (BASI), Air Safety Interim Recommendation No IR 980253. The format used is to print each of BASI's concerns in bold type followed by CASA's response.
a) "The Independent review process for the introduction of airspace changes was removed when CASA, as the regulator and safety auditor of the airspace system, also actively assumed the primary role for the design, safety analysis, promotion and management of the Airspace 2000 program from Airservices Australia in late 1997.
Previously Airservices Australia conducted these airspace change activities and CASA had a clearly defined process for monitoring and evaluating this process. However, when CASA assumed the role formerly exercised by Airservices Australia, no system was put in place to ensure that CASA's own work was similarly evaluated for the Class G Airspace Demonstration. No such system is yet in place".
CASA Response:
In view of the fact that a review is being conducted in accordance with a Ministerial Direction, it is considered inappropriate to respond to the above concern at this time.
b)"The CASA safety case process did not provide an integrated summary of all hazards considered, and their associated risk levels, mitigators, and anticipated effectiveness of the mitigators. In addition, the CASA safety case process did not include a "full qualitative and quantitative evaluation by technical experts" of Airspace 2000 (which includes Class G Airspace). Such an evaluation was proposed by the acting Chairman of CASA in a letter to the Chairman of Airservices Australia following the CASA Board meeting of 25-26 September 1997".
CASA Response.
With the exception of the late changes made on 4 November 1998, the Authority considers that the safety case addressed the principal concerns mentioned above. The main hazards were identified and consolidated in the updated safety case, the remainder being contained in its appendices.
A multiple risk analysis of the Class G Demonstration was undertaken in line with accepted methodologies, any one of which would normally be considered as adequate, The analysis of risk associated with the Class G Airspace Demonstration included:
1. Quantitative modelling based data, validated models, and analysed assumptions (Airservices Safety Case - included in CASA Safety Case);
2. Experienced judgement (AEP) and UK CAA Review (see CASA Safety Case); and
3. Trial Implementation (BASI was involved in the monitoring process and was provided with regular reports).
c)"The pilot education programs of both CASA and the aviation industry, as primary mitigators for hazards associated with the airspace changes, were not implemented effectively (in terms of the originally planned program, as well as the changes introduced subsequent to the issue of Aeronautical Information Publication Supplement 48198). A lack of pilot knowledge continues to be a major operational safety concern".
CASA Response:
Noted. A comprehensive pilot education package was mailed out to every AOC holder, some six weeks prior to the original commencement date of the demonstration (the cost of which was $.5M). However, it is acknowledged that there were deficiencies with respect to pilot education in some quarters and that, with hindsight, such issues could have been better handled by all concerned. Some changes to airspace design were introduced two weeks prior to implementation, but these were minor in comparison to the overall package and did -not involve changes to pilot procedures. The Authority sent information on these changes to all pilots licence holders.
d)"There has been a lack of support from elements of the aviation industry for the conduct of the demonstration. Such a lack of support had been recognised by CASA and a UK Civil Aviation Authority review team (engaged by CASA), as a significant risk to the success of the demonstration".
CASA Response.
Noted. As pointed out by BASI, both CASA and the UK CAA Review Team recognised the apparent lack of support by some elements of the aviation industry and the potential risk to the success of the demonstration. It is considered that there might have been greater industry support had there been more active industry involvement earlier in the proceedings leading up to the demonstration which, in turn, would have probably led to better understanding and hence pilot education in the industry.
e)"There are continuing problems associated with congestion of the NAF, a planned primary mitigator for hazards associated with the changes. This frequency congestion can prevent the transfer of vital information between pilots".
CASA Response:
Problems of congestion on the NAF were identified as a potential hazard prior to the demonstration but it was determined that this hazard could only be assessed fully during the course of the demonstration. This was covered in the report prepared by the UK CAA. This matter was also raised, and addressed, in CASA's monitoring reports which showed that congestion was limited to two periods of short duration at peak times each day. Some of the pilot reports received, from aircraft operations conducted at higher altitudes, indicated higher levels of congestion than was observed by CASA staff.
f)"The Airspace 2000 plan proposed the introduction of Class E Airspace corridors through Class G airspace on any route where traffic density required, or where such corridors were requested by industry. These E corridors were a planned mitigator against the removal of DTI, but were not implemented for the Class G Airspace Demonstration".
CASA Response:
It would appear that there is a misunderstanding of the concept with respect to E corridors. Class E Airspace was available from 8,500 FT above the entire area covered by the Class G Airspace Demonstration. 'E' corridors were planned as a mitigator for the removal of DTI further west, outside the radar environment.
g)"There are safety deficiencies associated with the current frequency management procedures, particularly during departures and arrivals at uncontrolled aerodromes (as shown in the occurrences described above). Pilots are required to monitor a number of different frequencies during these high workload phases of flight and may consequently not receive critical radio transmissions, or may receive late advise of other traffic".
CASA Response:
Noted. This is a complex and controversial issue. It is acknowledged that there were some workload difficulties associated with frequency management. The changes introduced on 4 November 1998 which mandated the M13Z frequency in MTAs alleviated the problems for arriving/departing RPT flights.
h)"Pilots and air traffic services staff have been advised of changes to the demonstration through numerous Notices to Airmen, which have been issued In an ad hoc and reactive manner. This continues to cause confusion among pilots and air traffic services staff".
CASA Response:
This criticism is acknowledged. At the time when the demonstration was terminated, action was well advanced to issue a replacement AIP Supplement (intended to be 69198). The intention was that this AIP Supplement should replace AIP Supplements 48198 and 66198, together with all of the NOTAM that had been issued. The intended replacement AIP Supplement consolidated all material into a single document, the purpose being to minimise the risk of confusion.
i)"As yet, the investigation team has not found evidence to indicate that
CASA's safety case process has considered the following safety issues
associated with the Class G Airspace Demonstration:
The full impact of each of the changes to the Class G Airspace Demonstration procedures and design that were implemented subsequent to the issue of Aeronautical Information Publication Supplement 48198 on 13 August 1998";
CASA Response:
Changes introduced subsequent to the issue of AIP Supplement 48198 were not subject to the safety case process because they were introduced to address concerns raised by the airlines which, principally, focussed on problems associated with frequency management and workload. It is acknowledged that changes introduced after the demonstration commenced were not subject to a formal safety analysis process.