Gentle_flyer, Jack and co I suggest that you crosscheck for any known BOS/LOSA occurrences that have been reported by responsible controllers to the ATSB but not investigated in the weekly summary page, see here:
Aviation weekly summaries
Presumably controllers would have kept a record of the date etc when they submitted the AAIN so you should be able to narrow down the search.
If after conducting such a search there is still no record showing of the controller's incident report...well then "Houston we have a problem"!
Q/ Is the ASA SMS incident/accident reporting system linked to the ATSB AAIN system? If so is that the way controllers generally submit a AAIN?
Then we could have two scenarios: a) It could be that ASA have a filtering system that checks the AAIN before it is sent to the ATSB; b) the ATSB is filtering the AAINs submitted for BOS/LOSA incidents.
The other questions that need to be asked if the incidents are all in the weekly summary database (other than the obvious on why the bureau isn't at least doing a preliminary investigation/report as is required by Annex 13): a) Are the BOS/LOSA notified incidents that are not investigated being forwarded to ICAO; if that is a yes and there is a reasonable amount of them then b) why is ICAO not picking up on a very disturbing and obviously growing trend?
The following are examples (before the bureau was Beakerised) of good solid 'Safety Recommendations' generated from findings gathered in the course of proactive ATSB investigations into BOS/LOSA incidents.
Aviation safety issues and actions; 07 June 2004
Closed - Partially Accepted
http://www.atsb.gov.au/publications/recommendations/2004/r20040062.aspx
ASA Response:
“I write in response to a letter from (name deleted) which was dated the 18th of August 2004. This letter indicated that our previous response to recommendation R20020062 was not accepted by the ATSB as it was believed that Airservices Australia had taken the literal interpretation of the recommendation and had focused on visual separation. The letter suggested on the basis of a list of incidents provided that Airservices Australia take a broader review of the effectiveness of Airservices Australia's check and training program in the area of procedural control services.
Following receipt of this letter, (name and position deleted) undertook a review of the occurrences provided (see commentary provided at Appendix A). This review compliments the analysis completed for the Breakdown of Separation (BoS) Review which was conducted in 2003, and the post-implementation review of the associated BoS Recommendation project which also evaluated incidents from a controller performance stand point. In neither review did Airservices Australia identify unhealthy norms or systemic performance issues within the procedural Tower environments. These reviews conclude that Airport Services conducts performance checks in accordance with the requirements of the CATSOAM.
The mandated CATSOAM checking regime is complimented by the Cross Unit Evaluations which are conducted on an annual basis within Airport Services. This program demands that a selected ATC from a like type tower (eg GAAP, regional, radar) evaluate the operations at another Tower. The Tower Manager and one other controller are checked by the visiting ATC to ensure that the standard of checking is maintained at the highest level. A full and comprehensive report is supplied after each of these station checks.
Each year like type tower conferences are held [GAAP, Regional and RADAR] and all aspects of check and training are raised in the forum.
As recognised in your letter, one of the most difficult aspects of Regional Tower Control is the concept of procedural separation and its application in the different classes of airspace and different categories of aircraft. The number of ATC's that fail to achieve rating standard in our regional ports is testimony to the importance of this concept being fully understood.
The training for rating and subsequent checks to maintain ratings, is intensive and exhaustive, and we remain convinced that we do not have a systemic problem with our checking regime for procedural towers.”
Appendix A
Hamilton Island 25/5/1999
No separation standard was applied.
Argyle WA 19/3/2001
Not a Tower issue.
Tamworth 27/6/2001
This is not a procedural separation issue for the tower as such. The aircraft was on a visual approach entering the circuit and failed to join final as instructed resulting in the aircraft flying through final. The controller was not required to apply a procedural standard as he was using visual separation at the time. This occurrence is a failure on the pilot in command to comply with procedures.
Albury 8/7/2002
In this breakdown, the understanding of the procedural separation requirement is quite clear. The phraseology was poor.
Mackay 16/11/2002
Separation Standard was not applied.
Mackay 29/1/2004
Separation Standard was technically infringed as the ATC used TSAD to establish one aircraft OCTA. The ATC fully understood the procedural standard.
Hamilton Is 17/7/04
A procedural standard had been established between the aircraft. Misunderstanding of circuit entry direction then led to a breakdown in separation.
Closed - Not Accepted
http://www.atsb.gov.au/publications/recommendations/2004/r20040063.aspx
ASA Response:
“On 1 September 2005, Airservices Australia amended the Manual of Air Traffic Service to completely remove the previously amended section 4.5.2.3 relating to the provision of aerodrome traffic information.
On 16 September 2005, the Civil Aviation Safety Regulation Part 172 Manual of Standards was amended, after agreement between CASA and Airservices Australia, to state:
When aircraft are operating visually as aerodrome traffic ATC must issue 1 or more of the following:
1. clearances designed to maintain separation
2. sequencing instructions relevant traffic information”
Separation Breakdown: SAAB 340, VH-OLM and Dash 8, VH-TQV; 17 January 2005
Closed – Accepted
http://www.atsb.gov.au/publications/recommendations/2005/r20050010.aspx
Closed - Partially Accepted
http://www.atsb.gov.au/publications/recommendations/2005/r20050011.aspx
“As a result of issues previously identified by Airservices Australia just prior to this recommendation, a number of systemic controls were introduced to ensure that controllers are aware of the importance of the separation assurance provisions of MATS 4.1.1.4. These measures included amendment to MATS 4.1.1.4 to reflect the full intent of Separation Assurance, the development and delivery of a refresher training module on separation assurance, and the inclusion of separation assurance criteria in Performance Assessment Reports. There is no recent evidence of the existence of an ongoing systemic issue.”
These days we get soft cock safety issue statements that are ultimately responded to by some crat with a PHD in spin....hmm FFS bring back our bureau!
