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'

atsb and report quality
 

Here it is:

Investigation: AO-2011-090 - Loss of separation involving Boeing 737, VH-VZC and Boeing 737, VH-VOT at BLAKA

and from Ben at How AirServices Australia endangered two 737s in 2011 | Plane Talking , the following comments:

Come on Senators, we have to stop this risk.

Question is, when will the FAA come down on us and call for a downgrade of our access to the US market???

Long gone are the days when a controller will admit a f**kup - they now trot out every excuse under the sun . :yuk::yuk::yuk:

So there's more unreported than these listed between 07-12???

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:ugh:
Investigation: AR-2012-034 - Breakdown of separation between aircraft in Australia: 2008 to 2011

ps This occurrence appears at #25 from above!:ok:

Sarcs,
The 'Responses' could almost be cut and paste...

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!!:E

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?

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:ugh::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 :suspect: that would be something the good Senators and ICAO would be extremely interested in!:cool:

GF if your interested here are the ATSB BOS/LOSA incidents from 2000-2006:

Good lesson for those in row zero: keep your ears open and try to work out who's close by.

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.

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"!:cool:

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?:confused:

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.:ugh:

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.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!:{

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??

Heads up Sarcs, GF called you Shirley. :D

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???. http://images.ibsrv.net/ibsrv/res/sr...ilies/evil.gif

I fancy that the - ASA-ATSB-MOU – document may have some relevance in the upcoming discussion.

From Zippy – usual rules.

P4 a.k.a. the Ferret.

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

Well there’s a challenge that I would be mad not to accept!!:E

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’:yuk: 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:hmm::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:However (and this is where it starts to get murky!:ugh:) Beaker and co have created a ‘hoodoo voodoo’ legal loophole and it all comes back to Beaker’s ‘notified difference’ in 2011: And if you reread 7.7 above the key words are….“If a State conducts an investigation” and 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???:ok:

Sarcs,

'Officially' its only BoS that are IRM's

I'm not sure what the official line is on LoSA

Hempy thanks for that:ok:...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!

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).

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!:ok:

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!

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.