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-   -   QF near miss over Great Australian Bight (https://www.pprune.org/australia-new-zealand-pacific/523934-qf-near-miss-over-great-australian-bight.html)

west atc 22nd Sep 2013 07:29

I'm very curious as to how this incident made it into the public domain so quickly, there are loss of separation incidents frequently all over the world but they don't usually make it into the public domain so quickly if at all.
Who leaked this to the news agencies and what is the agenda for doing so, I feel for the controller involved, he or she would be feeling bad enough without reading in the papers that their mistake "nearly cost the lives of 600 people". I know news has to be dramatic to make an impact but as far as I can tell there was no collision risk and the controller picked up their mistake very quickly.

"There are a lot of places in the world that that recommend offsets. (See Africa). Honestly, with the accuracy of GPS's these days, it is one more defence mechanism to avoid swapping paint in the cruise."

I wouldn't advise this when flying through UAE airspace, the tracks are separated by less than 6nm at some points so if you offset you could get close to traffic that is right beside you!

Spotlight 22nd Sep 2013 07:47

Would be interesting to know if both aircraft were flying 15a planned TAS, or otherwise.

Jack Ranga 22nd Sep 2013 08:15

Bloggs, there are stringent rostering rules for ATC's. You can, if you choose, work up to 10 shifts in a row. You CANNOT & WILL NOT be rostered anywhere near that. There are defined break periods between shifts.

There are fatiguing parts of the roster, particularly if you are Regional Services and get to work single person doggos, fatiguing & dangerous.

mikk_13 22nd Sep 2013 08:34


there are loss of separation incidents frequently all over the world
You are right there are.

The difference is where. Places like swissradar, where they move hundreds of thousands of flights through sectors the size of a bees dick. This should not happen over Adelaide. It is ridiculous. This is why there should be two pairs of eyes per radar.

I think the ASA pr machine is in over drive. Check out some of the comments in the sandilands news.

Capn Bloggs 22nd Sep 2013 08:56


Originally Posted by Jack
You can, if you choose, work up to 10 shifts in a row. You CANNOT & WILL NOT be rostered anywhere near that. There are defined break periods between shifts.

I've heard lots of ATCs in my time. Being able to work 10 days straight in that job is not good, IMO.

DraggieDriver 22nd Sep 2013 09:08


Would be interesting to know if both aircraft were flying 15a planned TAS, or otherwise.
Anything with an FMC and running on Cost Index will not be maintaining a constant planned TAS - actual TAS will change dynamically based on wind, & weight throughout the flight. With ADS-B and/or CPDLC TAATS has real-time access to the TAS. If TAATS does not use this information then a problem exists at that end.

Jack Ranga 22nd Sep 2013 10:09

Bloggs, 10 shifts in a row is probably not a good idea. I doubt ASA would function without it.

Plazbot 22nd Sep 2013 18:30

You could write a entire thesis on how the ability of 10 shifts in a row has contributed to AsA's current state.

CBTC

noknead 22nd Sep 2013 22:12

While 10 shifts in a row is a big issue, it is manageable, and also by choice.

A bigger concern is 2 early shifts (6am starts) followed immediately by 3 night shifts (single person) in a row. :zzz: This is the standard roster, but I believe is being phased out.

For those who don't know, 06 to 1500, 06 to 1200 then back the same day for the first of three 2300 to 0600. It's a bit like packing 5 shifts into 4 days.

And don't even start on the "Grey" Doggo issue......

I once upon a time thought ATC's were also subject to CAO 48 Flight (work) Time Limitations. It appears this is not the case. Could someone please set me right on this. :confused:

Thank you.

004wercras 23rd Sep 2013 01:26

This incident brings back to mind a discussion I was involved in back in 2000 as to whether a U/S TCAS should be a MEL item or whether it should result in an AOG. Makes you wonder that if James Reasons Swiss cheese had really lined up with this QF occurrence and both aircraft had U/S TCAS what would the result have been?
Also there has been a lot of talk about the controller being stood down. Pending an investigation this is a totally appropriate measure. If ASA exhibit a just culture then the controller being stood down pending an interim investigation is not punitive, and nor should it be. One would assume that the controllers colleagues and supporters are doing just that at the moment, looking after their colleague.

One would hope that the ATSBeaker will look at all aspects of the controllers 'alleged' mistake including;

- As mentioned earlier on this thread, what were the controllers shift patterns during and leading up to the occurrence, how many days straight, length of shifts, overtime, and what activities took place on the controllers days off?
- Work environment including management support and adequate breaks. Was there a controller shortage leading up to and during this occurrence?
- Training. The quality, depth and adequacy of the controllers training, was it commensurate for his/her role?
- Incident reports. Has there been any systemic issues or increase in controller mistakes that can be attributed to the port in question or across the organisation in general?
- CAsA oversight - Has CAsA audited ASA's method of creating shifts, controlling fatigue and ASA's support measures for affected controllers?
- Will ATSBeaker be investigating the aircraft in question with the U/S TCAS? Is there a pattern of unserviceabilty with the aircraft in question? Is there a higher than average occurrence rate across the airline operation in relation to the flying of aircraft with busted TCAS, even if it as a MEL item?

I believe the ASA's frontline people work extremely hard under some pretty piss poor conditions. I hope that Management and their penny pinching bureaucratic attitudes is not a causal factor in this near disaster.

tyler_durden_80 23rd Sep 2013 02:06

Working as a pilot or ATC, when you get it right no one remembers, when you get it wrong no one forgets.

Jack Ranga 23rd Sep 2013 02:07

One goat...........

blueloo 23rd Sep 2013 03:21


I hope that Management and their penny pinching bureaucratic attitudes is not a causal factor in this near disaster.
I think it is a given that with current thinking in Australian Corporation "Management" that this will never be a finding.

Hempy 23rd Sep 2013 06:01

I hear the 'Fatigue Management System' at ASA is 'World's Best Practice'. Surely robust fatigue management means any fatigue related issues are 'operator error' ...if one was forming a legal defence for example

sunnySA 23rd Sep 2013 11:23

mikk_13

Being 1 miles off track makes dick all difference inside radar.
Really, given that some routes are based on minimum lateral tolerances from either other routes, active restricted areas or a different controllers airspace then 1 mile could make all the difference. Remember that ATC can display relevant routes in their airspace and if you haven't been cleared direct then ATC would expect to see you on the airways and on the line.

flightfocus 23rd Sep 2013 14:40

Hempy,


I hear the 'Fatigue Management System' at ASA is 'World's Best Practice'. Surely robust fatigue management means any fatigue related issues are 'operator error' ...if one was forming a legal defence for example
Good old Worlds Best Practice - a euphemism for barely average. :(

Why don't these Australian corporations strive to be the best, as they once were? And they were proud of it! Qantas and the corporate disdain of its Engineering Dept is a relevant example.

A common (deliberately encouraged by ASA Mgmt) misunderstanding among ATC's - and it would seem pilots - is that the 'Fatigue Management System' is there to protect them. WRONG! :=

In reality it is a game of pass the parcel, and in this game the 'parcel' is the perceived risk of letting the fatigued controller in on the play.

For example, the controller doing the previously mentioned 10th shift, may have a 'High' fatigue risk. ASA still need a bum on the seat, so they 'calculate' the risk and then the 'appropriate' manager signs you off. Good to go.

Of course this only happens once you are at work, so you won't have to worry if your that tired you have a microsleep behind the wheel on the way in.

The controllers fatigue, and resulting impaired cognitive ability is only ever really addressed by 'controls' that include such gems as 'turn the lights brighter' and 'drink more coffee' - and yes I am serious!!! :confused:

So effectively, ASA Mgmt have introduced this 'Best Practice' system so that they can 'accept the risk' and have a 'robust' system that allows them to stick tired controllers in front of a console.

The only thing preventing a controller working endlessly is the protection of the certified agreement.

And all of this has been implemented so that they no longer suffer the embarrassment of having to declare airspace TIBA due to an empty console.

And of course that is related to the 'staffing' issue that no one will admit to, which is why we have ASA changing an historically proven '2 strikes your out' training program, with the modern soft and fluffy 'keep going till you get it right because everyone gets a medal these days' system.

The pilot community must fight to maintain the protection of duty limit times. The equivalent of a flight being cancelled due to the crew being out of hours would happen numerous times a day within ATC if we had a similar system, therefore we can not have a system that effective. :{

Sad, but true.

Plazbot 23rd Sep 2013 14:55

The concept of world's best practice perpetuates constant service degredation. Ifyou are doing something extra, you stop doing it because noone else does and claim you now conform to best practice. The end state for ATC is a boy scout with a flight radar app on his iphone and a loud speaker.

mikk_13 23rd Sep 2013 18:10


Really, given that some routes are based on minimum lateral tolerances from either other routes, active restricted areas or a different controllers airspace then 1 mile could make all the difference. Remember that ATC can display relevant routes in their airspace and if you haven't been cleared direct then ATC would expect to see you on the airways and on the line.
Ok so in this respect it does make a difference. But in the case of the flight crew on the forum asking about offsetting 1nm to avoid opposite traffic it will have very little effect as it is normal that aircraft are not flying on the published routes.

Plazbot 23rd Sep 2013 19:57

Mikk, I agree with most of your sentiment but some airspace is set up extremely tight on tolerence. Where I work we have four routes all less than six miles apart. As soon as anyone offsets 5 miles is lost.

I don't understand why a supposedly tier one nation like Australia still does not properly utilise RNP 1 and 5 design. It is an enormous place. With little traffic even in the allegedly dense areas. Where I work we run close to 800000 movements with less than 100 controllers. Australia runs about 1.5 million with 800 odd controllers. The system and design in Australia is decades behind the curve.

Sarcs 23rd Sep 2013 21:47

"Good old Worlds Best Practice - a euphemism for barely average."
 
Top post award for flightfocus!:ok: Nails the real issues behind all the.."he said she said"..&.."if in doubt cover your sorry arse by blaming the pilot (or in this case the ATC controller)"...blahblahblah...:ugh::ugh:


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