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ASA does it again - 2011 OOL near miss investigation released

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ASA does it again - 2011 OOL near miss investigation released

Old 5th Mar 2013, 23:51
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ASA does it again - 2011 OOL near miss investigation released

ATSBeaker has release it's finding into the 737 near miss over OOL.
Full report on the ATSBeaker website, and Ben Sandilands has written a good piece on it already.
Needless to say it doesn't appear that ASA have learned their lesson, as usual, as not much has changed, they offered a shallow mitigation strategy which in usual fashion contained empty promises and hollow words. Perhaps the CASA ought to finally audit it's son, the ASA?? Unlikely.

Once again we have some familiar root causes - poor training, idiot management, and an exhausted group of Controllers at the coalface having to endure the misery of incompetent executive actions.

'Safe skies are no longer Australian skies'
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Old 6th Mar 2013, 04:19
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Long gone are the days when a controller will admit a f**kup - they now trot out every excuse under the sun .
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Old 6th Mar 2013, 05:00
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Long gone are the days when a controller will admit a f**kup - they now trot out every excuse under the sun .
So there's more unreported than these listed between 07-12???

BOS and LOSA reported events within CTA: 01/01/2007 – 11/10/2012


2. http://www.atsb.gov.au/publications/investigation_reports/2012/aair/ao-2012-132.aspx

3. http://www.atsb.gov.au/publications/investigation_reports/2012/aair/ao-2012-119.aspx

4. http://www.atsb.gov.au/publications/investigation_reports/2012/aair/ao-2012-101.aspx

5. http://www.atsb.gov.au/publications/investigation_reports/2012/aair/ao-2012-048.aspx

6. http://www.atsb.gov.au/publications/investigation_reports/2011/aair/ao-2011-127.aspx

7. http://www.atsb.gov.au/publications/investigation_reports/2012/aair/ao-2012-085.aspx

8. http://www.atsb.gov.au/publications/investigation_reports/2012/aair/ao-2012-008.aspx

9. http://www.atsb.gov.au/publications/investigation_reports/2012/aair/ao-2012-087.aspx

10. http://www.atsb.gov.au/publications/investigation_reports/2011/aair/ao-2011-136.aspx

11. http://www.atsb.gov.au/publications/investigation_reports/2010/aair/ao-2010-104.aspx

12. http://www.atsb.gov.au/publications/investigation_reports/2012/aair/ao-2012-047.aspx

13. http://www.atsb.gov.au/publications/investigation_reports/2012/aair/ao-2012-054.aspx

14. http://www.atsb.gov.au/publications/investigation_reports/2011/aair/ao-2011-011.aspx

15. http://www.atsb.gov.au/publications/investigation_reports/2012/aair/ao-2012-030.aspx

16. http://www.atsb.gov.au/publications/investigation_reports/2012/aair/ao-2012-029.aspx

17. http://www.atsb.gov.au/publications/investigation_reports/2012/aair/ao-2012-012.aspx

18. http://www.atsb.gov.au/publications/investigation_reports/2011/aair/ao-2011-054.aspx

19. http://www.atsb.gov.au/publications/investigation_reports/2011/aair/ao-2011-010.aspx

20. http://www.atsb.gov.au/publications/investigation_reports/2011/aair/ao-2011-147.aspx

21. http://www.atsb.gov.au/publications/investigation_reports/2011/aair/ao-2011-144.aspx

22. http://www.atsb.gov.au/publications/investigation_reports/2011/aair/ao-2011-142.aspx

23. http://www.atsb.gov.au/publications/investigation_reports/2011/aair/ao-2011-131.aspx

24. http://www.atsb.gov.au/publications/investigation_reports/2010/aair/ao-2010-050.aspx

25. http://www.atsb.gov.au/publications/investigation_reports/2011/aair/ao-2011-090.aspx

26. http://www.atsb.gov.au/publications/investigation_reports/2009/aair/ao-2009-080.aspx

27. http://www.atsb.gov.au/publications/investigation_reports/2010/aair/ao-2010-102.aspx

28. http://www.atsb.gov.au/publications/investigation_reports/2009/aair/ao-2009-056.aspx

29. http://www.atsb.gov.au/publications/investigation_reports/2010/aair/ao-2010-014.aspx

30. http://www.atsb.gov.au/publications/investigation_reports/2007/aair/ao-2007-002.aspx

31. http://www.atsb.gov.au/publications/investigation_reports/2007/aair/ao-2007-003.aspx

32. http://www.atsb.gov.au/publications/investigation_reports/2007/aair/ao-2007-048.aspx

33. http://www.atsb.gov.au/publications/investigation_reports/2007/aair/aair200701982.aspx
But let's not worry because the bureau are in the process of completing an investigation into BOS and LOSA occurrences in OZ...just don't hold your breath as we have only gone past the anniversary of when the investigation was opened
Investigation: AR-2012-034 - Breakdown of separation between aircraft in Australia: 2008 to 2011

ps This occurrence appears at #25 from above!
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Old 6th Mar 2013, 07:24
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Sarcs,
The 'Responses' could almost be cut and paste...
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Old 6th Mar 2013, 08:27
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I agree Hempy they're very similar throughout...I also noted that there was 13 occurrences in 2012...which won't be incorporated in the ATSB report.

There is hope though that the report will come out soon as the green caterpillar is nearly full grown!!
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Old 6th Mar 2013, 08:55
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Sarcs,

You have been busy on the ATSB website!

2011 and 2012 look pretty bad for AsA.

Do you think ATSB investigates every BOS and LOSA that they receive from AsA? And if they don't how would we know given that the list is only from BOSs and LOSAs investigated by ATSB.

Hmmmm...What an interesting possibility?
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Old 6th Mar 2013, 10:39
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Do you think ATSB investigates every BOS and LOSA that they receive from AsA? And if they don't how would we know given that the list is only from BOSs and LOSAs investigated by ATSB.
That would be very disturbing GF that the ATSB would choose to not investigate a BOS/LOSA event, which by ICAO definition is a 'serious incident'. However the bureau has a notified difference that does allow them the option of not investigating:
Reference: AIP SUPPLEMENT (SUP) H12/11 DATE: 5 MAY 11
PG 65 Para 5.1.1
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.
Even if the bureau was crazy enough or in such current disarray that they chose not to investigate a BOS/LOSA they would still be obligated under Annex 13 section 4.1 to fwd the occurrence notification to ICAO.

If they haven't done that...wweeell that would be something the good Senators and ICAO would be extremely interested in!

GF if your interested here are the ATSB BOS/LOSA incidents from 2000-2006:
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Old 6th Mar 2013, 10:47
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Good lesson for those in row zero: keep your ears open and try to work out who's close by.
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Old 6th Mar 2013, 20:20
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Pick one of the three: (i) Pilot error; (ii) Controller error; (iii) LAME error.

Must be tough for DoIT to manage all of the miscreants within our pristine, world class systems.


Last edited by Kharon; 6th Mar 2013 at 20:22. Reason: Just lurv the pig in Blue
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Old 7th Mar 2013, 03:00
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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!
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Old 7th Mar 2013, 09:21
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Sarcs,

Thanks for all the research and information.

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.

The interesting part is that they are obviously not all investigated as evidenced by the ATSB list in the main investigation section. And we are apparently talking about some really serious ones according to some guys in BN Centre!

So the question becomes why in a time of heightened interest from Senators etc would the ATSB either a/. not investigate all BOS/LOSAs sent their way or b/. have some sort of secret squirrel MOU with AsA agreeing to investigate them but just not list them on the general investigation list so people like BS gives AsA stick on Plane Talking every time one is published??

One of course presumes that AsA investigates all BOS/LOSAa that are put into the AsA database. I mean that's why Airservices is there for ie stop jets bumping into each other so they at least would surely internally have to investigate every BOS/LOSA wouldn't they?

I mean if AsA are not internally investigating all the BOS/LOSAs and neither is ATSB we are going into territory I just can't believe its true. It sort of destroys the whole safety management system designed to be in place.

Nah, it just would not happen in Australia.....surely??

Last edited by Gentle_flyer; 7th Mar 2013 at 09:26.
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Old 7th Mar 2013, 19:37
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Heads up Sarcs, GF called you Shirley.

I would love to get a look at the ICAO data base, just to see how many of the ASA coalface reports filter through. There's probably some form of dodgy unique exemption which prevents compliance with ICAO requirements.

Howzabout :100 logged with ASA, 60 through the filters to ATSB, 20 through the filters to ICAO; what a story - that may just get a bit of attention.
How would we find out???.

Last edited by Kharon; 7th Mar 2013 at 19:38.
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Old 7th Mar 2013, 23:28
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I fancy that the - ASA-ATSB-MOU – document may have some relevance in the upcoming discussion.

From Zippy – usual rules.

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Old 8th Mar 2013, 00:05
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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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Old 8th Mar 2013, 05:09
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Sarcs,

'Officially' its only BoS that are IRM's

Originally Posted by AIP ENR 1.14
REPORTING - ALL AIRCRAFT OPERATIONS
2.1 IRM
2.1.1 IRM for all aircraft operations are:

e. breakdown of separation standards, being a failure to maintain a recognised separation standard (vertical, lateral or longitudinal) between aircraft that are being provided with an ATC separation service.
I'm not sure what the official line is on LoSA
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Old 8th Mar 2013, 05:32
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Hempy thanks for that...I guess a LoSA could be a RRM, maybe GF and co would know more about that. I'm guessing it would be in the definitions section of the ASA SMS manual and incident/accident reporting database.

However it still doesn't change the fact that..."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..." i.e. it is acknowledged that such incidents should be submitted to the ATSB!
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Old 8th Mar 2013, 08:27
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Quick question for the non-controllers on this thread, do you know what LOSA is? By definition there was no loss of separation, so any discussion of avoiding action is moot. Secondly, ICAO has no relevance because LOSA is a purely ASA invention. No other ANSP has SA, so there can be no LOSA.

All BOS/LOSA events are investigated by ASA because the first thing that happens is the controller/s is/are suspended. The awkward truth is that as often as not it was simply a case of controller or crew error. Sometimes there just aren't any systemic issues (not the case for the OOL BOS by the sound of it though).
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Old 8th Mar 2013, 10:04
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Nautilus I'm not a controller so what you say is eagerly absorbed somewhere in my grey matter i.e. I'm open to being educated!

Now that I've 'absorbed' your post I've got a couple of questions and observations...

If, as you say, a LoSA (which I thought meant 'loss of separation assurance') is a purely ASA recognised incident then why out of the 33 events listed above for 07-12 has there been 11 LoSA events that have been investigated by the ATSB?

None of those events were downgraded to a level 5 investigation and all of the completed investigations carry a full 'final report'. Which would indicate that a LoSA is, at least sometimes, regarded by the ATSB as serious enough to divert their limited resources to investigating.

So NB is this adhoc effort by our bureau to investigate some of these LoSAs a purely Australian phenomenon for a ICAO accredited aviation accident investigative body to investigate? Or could it be that LoSAs are indeed recognised by ICAO as a reportable occurrance?

It is also worth noting NB that purely by the action of the ATSB initiating a full blown investigation into some of these, ASA defined, LoSA incidents that ICAO would (or should) automatically be notified as per Annex 13!

Last edited by Sarcs; 8th Mar 2013 at 10:06.
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Old 8th Mar 2013, 11:47
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AFAIK LOSA is purely an Australian thing, although if you search you'll find mention of "separation assurance" discussed in development of automated tools.

What's the difference between two events that only differ by 1NM when the controller wasn't actively separating? One missed by 4 miles and the other by 5. One is a BOS & one is not. They're equally dangerous and equally worthy of investigation.
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Old 8th Mar 2013, 12:38
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The point of sep assurance is for the controller to make separation occur, not just let it happen. Requirements, pegging speeds, interim levels instead of letting it run and monitoring. You could call it controller technique.

If I avoid a BOS by sheer dumb luck, by responding to a STCA alarm or by catching it just in time it's only one hole in the Swiss cheese away from a potential collision. It's only 30 seconds or a mile or two away from an accident. I'd call that worthy of investigation.

How is that grandstanding by boffins?
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