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-   -   Swiss Cheese ASA Style (https://www.pprune.org/australia-new-zealand-pacific/482162-swiss-cheese-asa-style.html)

Nautilus Blue 13th Apr 2012 08:30

The important thing is though that college has been removed from HR, and the head of training now reports direct to the CEO. That has to be an improvement.


are our skies as safe as we suppose them to be ?.
Could be better, could also be worse. I don't know of any ATC that won't fly as a passenger, yet. Personally I'd not fly at night, and if it weren't for TCAS I'd be worried. Most of the small percentage of the public who care would have trouble seeing past the spin, and there is only one way to prove there is a problem. Almost certainly it will get worse before it can get better.

Kharon 15th Apr 2012 22:16

My turn is it ?. OK
 

NB. - I don't know of any ATC that won't fly as a passenger, yet. Personally I'd not fly at night, and if it weren't for TCAS I'd be worried. Most of the small percentage of the public who care would have trouble seeing past the spin, and there is only one way to prove there is a problem.
The public should be made bloody well aware. The incumbent Minister surely must be culpable if there is an unthinkable.

Is it getting really, really messy out there ?. They talk about holes in the sacred cheese. Lets look at the ones we have lined up right now:-

Is CASA moribund; only capable of generating pointless, half baked administrative show cases, an endless amount of smoke, mirrors and a defence which reckons they have no responsibility ?. The whole sad, sorry edifice seems dedicated only to baffling Senators, Coroners, the Judiciary and any one else who crosses their twisted path.

Is ATSB emasculated ?; does it appear as the starved child of a loveless union. Bullied and beaten into cringing submission until the will to resist; let alone publish anything vaguely resembling a honest appraisal of the most probable and ranked contributing causes related to the incidents ?. The whole sad, sorry edifice seems dedicated only to baffling Senators, Coroners, the Judiciary and any one else who crosses their twisted path.

Is the ASA apparently suffering a combination of Casaititis and Atsbaphobia ?. At least the front line troops may hold their heads up. They have to; highly visible, easily located and providing an endless supply of ready to hand cannon fodder for the speedy abrogation of all responsibility. The whole sad, sorry edifice seems dedicated only to baffling Senators, Coroners, the Judiciary and any one else who crosses their twisted path.

If it was all found to be true, there is at least a Ministerial head in a metaphoric bucket available here. We only need an axeman to do the job; even only if for so small a reward as ensuring the travelling public may travel at night and have a fair chance of getting off at the other end before the pubs close.

Steam off.
Mutter, curse, mumble, curse, Click.

gobbledock 16th Apr 2012 01:07

Take a ticket and stand in line, it's my turn..
 

Is CASA moribund; only capable of generating pointless, half baked administrative show cases, an endless amount of smoke, mirrors and a defence which reckons they have no responsibility?.The whole sad, sorry edifice seems dedicated only to baffling Senators, Coroners, the Judiciary and any one else who crosses their twisted path.
Correct Kharon, you score a prize - 12 months free subscription to 'Flight Safety Pony Poo'.
That is their quest in life. To create spin and deflection and run from accountabilty. They cannot oversight or manage their own internal issues let alone negate the requirements of the aviation industry in all it's complexities. As an example talk to the new 'CMT participants' and you will learn that it has already disintegrated at the seams. Inspectors not allowed to travel to conduct work 'live in the field' due to 'budget restraints'. They are being advised to regulate via a keyboard! As if that works? Heaps of cost cutting taking place with these funds used to fund the Skulls golden dream of a training center of excellence in Brisbane! I am sure some of the re-budgeted lucre is also paying for senior heirachy to indulge in some additional international hoohah.


Is ATSB emasculated ?; does it appear as the starved child of a loveless union. Bullied and beaten into cringing submission until the will to resist; let alone publish anything vaguely resembling a honest appraisal of the most probable and ranked contributing causes related to the incidents?. The whole sad, sorry edifice seems dedicated only to baffling Senators, Coroners, the Judiciary and any one else who crosses their twisted path.
Correct. And again, Kharon you win a prize - This time you get to pick from the middle shelf. Up for grabs is a free SMS assessment, a ticket to the next CASA safety workshop at Tenterfireld or an oepning day pass to the Brisbane Field Office 'Center for Training Excellence'!
And yes the ATSB has been raped by bureaucrats who have recategorized incident/accident rankings, added some bureacratic garnish such as 8.7 investigations completed per 1000 hours investigative time, or some similar styled number fluffing techniques. The heart and soul of the ATSB has always been it's non politically stymied Investigators and the quality work they attempt to undertake on a shoe string frontline budget while being dominated by the Ministers whips.


Is the ASA apparently suffering a combination of Casaititis and Atsbaphobia ?. At least the front line troops may hold their heads up. They have to; highly visible, easily located and providing an endless supply of ready to hand cannon fodder for the speedy abrogation of all responsibility. The whole sad, sorry edifice seems dedicated only to baffling Senators, Coroners, the Judiciary and any one else who crosses their twisted path.
Again we have a winner !! Kharon, step right up and claim Australian Aviations Brown Logie Award. The Minister (rightful owner) is happy to pass it on personally!
Sadly ASA have been infected by a host parasite called Bureaucrat****is, a disease that is flourishing within Australia and spreading at an alarming rate within aviation and infastructure. The disease, which has been prevalent for eons within all walks of governemnt at all levels has become more recently discernable as the outbreak spreads uncontained. Symtoms often include the existence of lies and deception, spin, mathematical perentages banded about, overseas trips for cure finding missions, a distortion of the tongue in which words such as robust, underpinning, overarching and 'worlds best practise' are often spewed forth violently and reptitively.


We only need an axeman to do the job; even only if for so small a reward as ensuring the travelling public may travel at night and have a fair chance of getting off at the other end before the pubs close.
There is a high likelihood that the end result will be the occurence of TICK TOCK unless Axeman Xenophon can use his wood chopping skills to cut down this pillar of pony poo.

twa12 17th Apr 2012 07:49

Did hear a rumour that head of school might becoming from a well spoken, technical background person non-atc.

Kharon 17th Apr 2012 08:44

Cor, stone the bloody chooks,
 
To quote the Bard, (Toofey d' Brudge) – “if he could find a chook, in a chook house with a candle”; it would be a bloody site better than the purblind, home spun pony pooh we are 'hearing' about now. http://images.ibsrv.net/ibsrv/res/sr...lies/sowee.gif

Sandilands (Plane talking) is definably on to "it'; the tent children appears to be on fire.

GD – No apology – Tick tock indeed; and Noco (Cahones) watches as home burns. The silly sod doesn't even realise he is responsible even if he's retired to a high class chook house in a noise sensitive suburb, with hot and cold running kerosene showers.

Stone the bloody chooks. How ?, (someone tell me) in all the Hells would the country's reputation survive a mid air, now this sorry saga is all slowly becoming public knowledge.

A lot of good “standard” mandatory radio calls will do then. :ugh:

halfmanhalfbiscuit 17th Apr 2012 11:02


As an example talk to the new 'CMT participants' and you will learn that it has already disintegrated at the seams. Inspectors not allowed to travel to conduct work 'live in the field' due to 'budget restraints'. They are being advised to regulate via a keyboard! As if that works? Heaps of cost cutting taking place with these funds used to fund the Skulls golden dream of a training center of excellence in Brisbane!
Surely the inspectors need to get out and oversight industry. Certainly the Auditor General in Canada believes so.

Auditor General raises red flag over Transport Canada’s oversight of aviation safety

While Transport Canada requires yearly inspections, 70 per cent of aviation companies in Canada were not inspected in 2010-2011, Auditor General Michael Ferguson
Canada News: Auditor General raises red flag over Transport Canada

Sarcs 2nd May 2012 06:50

Is it just me or are these 'breakdown of separation' events becoming so commonplace that no one even bats an eyelash, I guess you could say that all the 'heavy tin' has TCAS these days....."ho hum"! or "tick tock"!

Ben's latest ATC/ATSB grab: Jet airliners played tag near Melbourne Airport says ATSB | Plane Talking

Kharon 3rd May 2012 09:12

Ministerial interest ??.
 
Snowy heard a whisper today, there are some positive steps, in the 'right' direction being taken, driven from quite high up. Any truth in it ??.

Curious and without fanfare even more so. Would be nice to say thanks, just for once.

Jack Ranga 3rd May 2012 14:17

In the good old days a jet didn't climb out under 300kts. It was published in our books. Then the accountants told the company to tell the pilots to climb at 'econ' speed or 'cost index' speed (whatever any of that means?). Nobody told the ATC's, got a few 'surprises' when it first started happening. Asking the pilot in front to climb not below 300kts fixed it.

Any inquiry conducted into these incidents wont give the real reason why these BOS's are happening with monotonous regularity. I can tell you some of the reasons, it started you know where, when someone who trained bank tellers believed that 'anybody' could do ATC. By the same premise, that means that 'anybody' could be a doctor.........right? Anybody could fly an FA18 mission into Iraq............right? Anybody could be a trapeze artist?

Blockla 4th May 2012 08:56


'anybody' could do ATC
Effectively true, as long as you have two arms can hold some ping pong bats and don't mind getting wet... oh no wait???

ferris 4th May 2012 09:00

No thoughts of returning to the Evil Empire, Blockla?

Kharon 7th May 2012 08:03

Tip of the iceberg
 
Any one catch the Melbourne - "Herald Sun" piece today.

Who knows - it's interesting though, when the CASA super spin - voice is onto it before the ink was dry. Hear it's been on Sky News. Still a rumor network ain't it ??.

Melbourne's crowded airspace dangers

Updated: 09:31, Monday May 7, 2012

Melbourne's crowded airspace is leading to dozens of close calls every week, according to a dossier compiled by the Herald Sun.

The paper said planes too close together, unsafe landings and mechanical malfunctions are putting thousands of lives at risk in the skies over Victoria.

The catalogue of chaos includes smoke or fumes in the cabin, pilots tracking for the wrong runway or airport, and birds flying into planes.

Other issues include dangerous goods on board such as explosives and carbon dioxide cylinders, communications system crashes, incorrect data entry or settings on flight computers, and call-sign mix-ups.

Many of the incidents go unchecked because safety authorities don't have the staff or resources.

'Experts have warned the crowded airspace above Melbourne, combined with fatigued pilots and air traffic controllers, could prove fatal on a mass scale,' the newspaper said.

Australian and International Pilots Association vice-president Richard Woodward was worried that financial conditions were driving all airlines to cut costs, including safety expenses.

'When things get a bit pear-shaped, they don't have the skills to recover, Mr Woodward said.

But Civil Aviation Safety Authority spokesman Peter Gibson said it was wrong to link the number of reported incidents with safety issues.

'Aviation is an extremely safe way to travel,' he said.
Sorry - no link - Sky News crib. Poor old Journo's, someone should tell them how things are.

Frank Arouet 7th May 2012 09:48

When the regulatory abilities of Airservices were taken from them and given to the CAA, the point of contact is probably Peter Gibson who will talk rubbish to you and blame AsA.

Just another of Mrs Palmers graduates.

It may be of interest to see how a certain representative body behaved in the YMML airspace steps, mostly done to discredit Dick Smith and a highly experienced Heavy RPT Captain, by a Private VFR Day pilot with no practicable experience, advocating non standard step slope.

No wonder they have meetings in telephone box's.

Tick Tok Peter!

thorn bird 8th May 2012 06:44

I heard there's a new charity raffle going around CASA.
First prize is a week, all expenses paid, at the new BN training school!!
Second prize is two weeks, all expenses paid at the BN...... Oh:}

Ex FSO GRIFFO 9th May 2012 13:56

AAhh....

Just give him the 'Area QNH'...and pi55 him orf.....

:}:ugh:

Service..?? Wot service..??)

Roger Standby 10th May 2012 09:31

You'd be amazed at the lengths they go to to avoid hiding the lack of staff numbers. In the old days, an ATC group (eg 3 or 4 sectors) would have a published minimum staffing level. That number would vary throughout the day depending on traffic levels.

As an example, a 4 sector group might have a requirement to have at least 7 controllers rostered and a minimum of 5 working allowing for sickies. If these minimums weren't met, an ESIR was put in and explanations would be required. It was a safety event! Notams were also issued.

Over time, these minimums were reduced and reduced until the paperwork trail and the embarrassment became so regular that the documents were scrapped and there is no longer any trail of when these situations take place. The minimum staff requirement for the 4 sectors these days is simply 1. As long as one body is sitting in a chair and the sectors can all be combined up and there is no declared TRA/TIBA, then minimums have been met.

Traffic metering? NOC help?? pfft! A break should be provided every two hours and is supposed to be mandated at least every 3 hours but often this just doesn't happen. Need a pee? Wait until a supervisor deems he isn't **** scared enough to sit and watch the screen for 3 minutes while you duck out for a quickie and leave nobody qualified to watch YOUR airspace. Better be careful tho, that supervisor is not responsible for what happens while you are gone.

Oh, the next shift has just gone down as well. Would you mind extending your 0600 shift through to 3pm? You can still legally make it back for the night shift tonight at 2300! Or better still, extend to 1600 and we'll come up with something in the meantime and get you back at midnight instead.:rolleyes:

Sarcs 10th May 2012 09:57

Roger Standby good post! From the heart and, dare I say, from a frontline tin pusher who knows and has experienced the decline.:ugh:

Which makes it all pretty scary stuff when your out there ploughing holes in the sky and keeping the blue bit on top....while one of you poor buggers are potentially distracted by having to hang on because of a **** scared supervisor waiting for a break in the traffic....sheesh...tick bloody tock!:{

Kharon 10th May 2012 10:24

Finally; at last.
 
An honest unit. I know this is a 'pilots' forum, but all day, every day, (Hiundai) we, (the pilots) depend so very much on what this group of unsung folk do, it's scary. Like dependable engines, when the doo doo (rare occasion) hits the windmill, there is the calm quiet voice of hope; fully trained and qualified, fit to work, not fatigued with back up.

I, like many depend on the fact (hope now) that they are there when most needed, it's an almost symbiotic relationship. Rarely does an ATC (stuff the spin) or FSO misread the unspoken prayer for service. Brothers in arms ?, you could say so without too much fear of contradiction.

Thank you Mr. Livingston, Selah.

That the ATC guy is whacked out, fatigued, buggered about or not able to go for a wee wee is unacceptable. If ever there was a need to ensure service it is now; perhaps the Naval check "3 greens" should be reinstated, for civil use. At least half the silly buggers would the check Gear Down somewhere between 1500 and 384 feet; but, who would be responsible for that?,

As Grip Pipe would say, yes Minister – it's all bollocks (at 300 knots a piece, (that's 600 knots closing which is 10 nautical miles per minute).

CASA fuss over pilots 1 minute on duty, but ATC (their remit), oh well, the lads and laddetes will cope.` Probably through sheer professionalism , but for how long?.

Steam off. :ugh:

gobbledock 10th May 2012 11:29

Roger Standby, 10/10 mate. Sadly what you are saying does not come as a shock.
How about Russell's salry be trimmed back to 250k, bonuses removed and maybe that money be converted into frontline manpower? Just a thought to begin with.

Senators, the public, and anyone with an ear - Are you hearing what we can hear? Yes you can did you say? You hear the 'tick tock' of the clock? Good.
The above example is amazing, incompetent Supervisors and a Controller that cant even take a piss due to staff shortage. Excessive fatigue and a host of other 'holes' are continuing to line up..Bloody disgrace.

Hempy 13th May 2012 09:44

It all started when the CAA was split and ASA was formed as a Government Business Enterprise, therefore no longer a 'public service' but existing to turn a profit and fork out a dividend into the big fat general revenue bucket each year. With status as a GBE, and more importantly transition to TAAATS, came wonderful new management principles...'Business Units', cost cutting, executive bonus's, empire building...and the bureaucracy increased exponentially.

In the mean time the training organisation was gutted (resulting in an Australia Day commendation from the CEO to the guttee...), the training of new controllers essentially stopped, rated controllers continued to leave, either retiring or leaving for the overseas job market ironically opened to them by ASA, and consoles became harder to man. Rather than admit that, while looking sensational on that financial years bottom line, it may have been an error long term in culling the training annex, faith was placed in a magnificent new way of managing less staff more efficiently...SDE. The fact that SDE is in fact less efficient than the previous group/team systems isn't either recognised or accepted at executive level, for obvious reasons, but it's true. And now ATC's have to risk their licence and/or the traveling public's safety to have a wee.

^^^ This is affordable safety.

5miles 13th May 2012 10:18


... and ASA was formed as a Government Business Enterprise
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.

ferris 13th May 2012 18:57

It's been an interesting exercise.

Instead of 10 clerks doing a role (say, payroll), they have 4. Of course, the 'manager' in charge (of whatever wanky name that dept now gets called), is on a massive salary with all sorts of 'performance incentives'. Probably cost neutral, but 5 less staff.

What's that, you say, staff numbers in total haven't gone down? Less people who actually do things (such as ATC), and many, many more people who are 'business development executives', 'stakeholder relationship managers' etc. etc.

The 'business', however, returns money to the govt.... Lets not mention that they charge for everything and don't provide much a service to aviation anymore (briefing offices, FSOs, etc. etc.).

The biggy (which the airlines don't seem to grasp) the cost shifting that goes on when AsA doesn't do things (like- provide controllers for volumes of airspace which are then flow-constricted or just closed, costing the airlines mega dollars in delays and track-miles). One day, someone will wake up, and realise just how much this illusion of productivity is costing the country.

But hey, the CEO gets a salary befitting a CEO, instead of a public servant's salary. :rolleyes:

Hempy 18th May 2012 07:53


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'....

Sarcs 31st Jul 2012 04:39

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.
Investigation: AO-2011-127 - Breakdown of separation - VH-YVA/VH-CGF, 59 km NE Armidale, NSW, 8 October 2011

So ATCers is the above amendment too little, too late? Is there more they could do to lessen the occurrence of these 'BOS' events (other than a frontal lobotomy of the execs)?

Good to see Ben Sandilands is still on the job::ok:

Air traffic officer had mental problem in AU near miss case | Plane Talking

Baileys 31st Jul 2012 04:52

Individual controllers could do their job?

Nautilus Blue 31st Jul 2012 07:38


So ATCers is the above amendment too little, too late?
You tell me,

Previously - TRAFFIC ALERT, TRAFIC IS ....., TURN LEFT/RIGHT HEADING ... IMMEDIATELY

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 :ugh:

mikk_13 31st Jul 2012 08:01

Probably would not have happened if there were two sets of eyes on the board.

But it isn't worlds best practice in australia, just in the rest of the world.

gobbledock 31st Jul 2012 10:36


But it isn't worlds best practice in australia, just in the rest of the world.
But I am sure that Russell and his Russellites would have used the pony pooh phrase 'world's best practise' in some of their monthly reports to the Minister for Mascot's office? They would have used 'world's best practise' in some of their spin doctoring and political wankery too......

le Pingouin 31st Jul 2012 15:08


So its a high priority alert, and the first response is to assess its validity :ugh:
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.

Jack Ranga 1st Aug 2012 04:11

Thing is & and we all know it....

Do you want a CBT trained controller or somebody who's not trained according to political correctness?

Sarcs 3rd Aug 2012 03:22

Lousy hand over!
 
Another BOS! Bad hand over gets the blame this time...

http://atsb.gov.au/media/3624100/AB2012088.pdf#page=24

Ben's take..

Air China, Qantas too close when Australian ATC forgot them | Plane Talking

I hope all these 'events' are being cc'd to Albo's circus!:E

gobbledock 3rd Aug 2012 10:48

TICK TOCK Albo is a c#ck
 

I hope all these 'events' are being cc'd to Albo's circus!http://images.ibsrv.net/ibsrv/res/sr...ilies/evil.gif
Better still, would love to be a fly on the wall and see the reaction on Albo and his band of merry trough dwellers faces when the first mid-air or mountain top smash occurs. Every day that goes by we get a day closer.Nothing is changing expect for the fact that the stakes are getting higher and the day is getting closer!
Tick tock

http://t0.gstatic.com/images?q=tbn:A...z-Uj7F4cd7n5dx

Kharon 3rd Aug 2012 21:07

For those left behind
 
Sandilands - BOS


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. :D


Robbovic 21st Aug 2012 03:22

"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.




Up-into-the-air 21st Aug 2012 10:20

asa and spin
 

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!!

Mimpe 26th Aug 2012 09:16

swiss cheese?
 
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.

Kharon 26th Aug 2012 22:04

Tired cheese?
 

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.

Sarcs 12th Oct 2012 00:40

ATC Senator X feels your pain?
 
Nick is on the job and I get the feeling he is going to kick some 'crat' butt next week at the Supplementary Estimates...Estimates daily programs – Parliament of Australia

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?

Answer:
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.
(c) Yes.

2. Yes.

3. Yes.

4. Yes.

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.
(d) Yes.
(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.
(b) No.
(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.

gobbledock 12th Oct 2012 01:27

Idiots
 

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.

There you have it. a safety critical part of aviation with next to nil oversight. But CASA has time to chase chopper pilots and punish pilots for forgetting to cross a T or dot an I in their log books?
How much is enough? Time to roll these clowns.

Sarcs 12th Oct 2012 08:07


There you have it. a safety critical part of aviation with next to nil oversight.
"But wait there's more your Honour!"


Question no.: 96
Program: n/a
Division/Agency: (CASA) Civil Aviation Safety Authority
Topic: Air Traffic Controller Incident
Proof Hansard Page/s: 52 (23/05/2012)

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.

Answer:
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"!:E


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