PPRuNe Forums - View Single Post - ASA does it again - 2011 OOL near miss investigation released
Old 8th Mar 2013, 00:05
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Sarcs
 
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Thanks FERRET and here's a link for it off the ATSB site:http://www.atsb.gov.au/media/1543248/mou%20between%20atsb%20and%20airservices.pdf

Heads up Sarcs, GF called you Shirley.
Well there’s a challenge that I would be mad not to accept!!

GF said: Checked with controllers and the general impression is a BOS/LOSA submitted to the Airservices safety database is an immediately notifiable to ATSB.

So the automation should ensure that the ATSB sees all of them.
Ok GF so that would make BOS/LOSA incidents ‘immediately reportable matters’ or ‘IRM’s.

Even if some BOS/LOSA were ‘internally screened or ‘Beaker screened’ and downgraded to ‘routine reportable matters’ or ‘RRP’s they should still all end up on the ATSB database (albeit buried in the weekly summaries section), this is also reflected in the ASA/ATSB MOU:
5.1.1 Notification to ATSB:

Airservices Officers, in fulfilling their reporting requirements for immediately reportable matters (IRMs) and routine reportable matters (RRMs) under the TSI Act should normally use the contacts identified in Attachment C.

It is acknowledged that a written report from Airservices, either as a follow up to an IRM or the submission of a RRM, will normally* be in the form of an ESIR1. (* Note: Beaker has included his favourite legal wriggle room word ‘normally’!!)
And by the terms of ICAO Annex 13 (Ch7 para 7.7 and Appendix C para 1 and part of 2) in ‘principle’ (key word as you will soon see and it’s not pretty!!) it should end up on the ICAO ADREP (ISTAR) database:
7.7 If a State conducts an investigation into an incident to
an aircraft of a maximum mass of over 5 700 kg, that State
shall send, as soon as is practicable after the investigation, the
Incident Data Report to the International Civil Aviation
Organization.

Note.— The types of incidents which are of main interest to
the International Civil Aviation Organization for accident
prevention studies are listed in Attachment C.

1. The term “serious incident” is defined in Chapter 1 as
follows:

Serious incident. An incident involving circumstances
indicating that an accident nearly occurred.

2. The incidents listed are typical examples of incidents
that are likely to be serious incidents. The list is not exhaustive
and only serves as guidance to the definition of serious
incident.

Near collisions requiring an avoidance manoeuvre to avoid
a collision or an unsafe situation or when an avoidance
action would have been appropriate.
However (and this is where it starts to get murky!) Beaker and co have created a ‘hoodoo voodoo’ legal loophole and it all comes back to Beaker’s ‘notified difference’ in 2011:
Para 5.1.1 and 5.1.2
Australia may not institute an investigation into all foreign or
Australian-registered aircraft involved in serious incidents.
Decisions on whether particular serious incidents will be
investigated will depend on resources and the likely benefit to
future safety.
And if you reread 7.7 above the key words are….“If a State conducts an investigationand that is where the ugliness within starts.

I would also argue that the legal eagles would debate Beaker’s obligations under Annex 13 (Ch 4 para 4.1) to send an occurrence notification of a serious incident to ICAO.

Why you may ask ?? There are too many wriggle room words (and Creamy can probably confirm this??) contained in…“Near collisions requiring an avoidance manoeuvre to avoid a collision or an unsafe situation or when an avoidance action would have been appropriate.”

Which in the literal sense, with a number of these BOS/LOSA events, ‘avoidance manoeuvre or action’ could automatically mean that any aircraft that wasn’t required to change it’s flight profile wasn’t defined as a ‘serious incident’, therefore negating Beaker’s responsibility to report the matter to ICAO.

However GF the only real way to confirm or deny this developing, potentially sordid and ugly ‘Shirley’ tale is to track the controller reported BOS/LOSA events and compare to the ICAO ISTAR database.

As Kelpie would say more to follow…that MOU is very interesting???


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