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What happened

On 30 March 2012, Airservices Australia was unable to resolve two short-notice controller absences for night shift coverage of the Kimberley and Cable airspace sectors, located over north-western Australia. A contingency plan was activated and a Temporary Restricted Area (TRA) initiated for that airspace from 0015 to 0515 Eastern Standard Time on 31 March.

Two aircraft separately entered the TRA without the knowledge of Airservices personnel. An Airbus A330 registered PK-GPA, on a flight from Denpasar, Indonesia to Melbourne, Victoria, was detected at 0500 when the flight crew contacted a Melbourne Centre controller because their aircraft was at the Brisbane/Melbourne Flight Information Region (FIR) boundary after transiting the TRA. The second aircraft, an A330 registered PK-GPO, on a flight from Denpasar to Sydney, New South Wales, was detected at 0641, when the crew contacted Melbourne Centre at the FIR boundary. The aircraft had been operating in controlled airspace for 86 minutes, without the knowledge of any controllers. The minimum standards for separation from other aircraft were met, but both situations constituted losses of assurance that separation would be maintained.

What the ATSB found

Overall, Airservices had many risk controls in place to manage the situation where it was unable to provide the published air traffic services (ATS) and had to activate a TRA. In this case, a TRA had to be activated at short notice in airspace adjacent to an international ATS provider, and a range of actions by operational personnel did not conform to expectations. Airservices’ risk controls were not robust enough to effectively manage this situation and ensure they would be made aware of all aircraft that were operating within the TRA.

The ATSB concluded that a number of procedures and processes were not fulfilled on the night of the occurrence and identified four safety issues: Airservices’ process for ensuring that all aircraft operating in the TRA were known to ATS; selection and preparation of personnel for the Contingency Response Manager role; the contingency plan testing and review process; and the absence of a defined process for recording the actual hours worked by Air Traffic Control Line Managers.

What's been done as a result

Airservices has revised its contingency plan documentation and procedures. In addition, its updated Fatigue Risk Management Requirements have addressed the recording and monitoring of the actual hours worked by Air Traffic Control Line Managers.

The ATSB is not satisfied that Airservices has adequately addressed the identified safety issues regarding processes for managing a Temporary Restricted Area to ensure that all aircraft were known to air traffic services and contingency plan testing and review effectiveness. As a result, the ATSB has made formal recommendations to Airservices.

The operator of the A330 aircraft, Garuda International, specified that, as the use of procedures associated with TRA activation was an infrequent requirement and not practiced in daily operations, it would ensure the procedures were reviewed as part of check and training programs.

Safety message

The occurrence provides a timely reminder to all organisations operating in high reliability systems of the importance of having multiple risk controls in place to effectively manage rare combinations of events during abnormal situations, and to regularly review the effectiveness of these controls.

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Safety issues

AO-2012-047-SI-01 - AO-2012-047-SI-02 - AO-2012-047-SI-03 - AO-2012-047-SI-04 -  

Temporary Restricted Area management processes

Airservices Australia’s processes for managing a Temporary Restricted Area did not effectively ensure that all aircraft operating in the Temporary Restricted Area were known to air traffic services.

Issue Number:AO-2012-047-SI-01
Who it affects:All aircraft operators
Status:Adequately addressed


 

Contingency Response Manager selection and preparation processes

Airservices Australia’s processes for selecting and preparing personnel for the Contingency Response Manager role did not ensure they could effectively perform that role.

Issue Number:AO-2012-047-SI-02
Who it affects:All Airservices Australia’s Contingency Response Managers
Status:Adequately addressed


 

Contingency plan testing and review effectiveness

Airservices Australia’s processes for reviewing and testing contingency plans did not effectively ensure that all documented contingency plan details were current and that its contingency plans could be successfully implemented at short notice.

Issue Number:AO-2012-047-SI-03
Who it affects:All Airservices Australia air traffic controllers
Status:Adequately addressed


 

Fatigue monitoring of Air Traffic Control Line Managers

Airservices Australia did not have a defined process for recording the actual hours worked by its Air Traffic Control Line Managers and therefore could not accurately monitor the potential fatigue of those personnel when they were performing operational roles such as a Shift Manager or Contingency Response Manager.

Issue Number:AO-2012-047-SI-04
Who it affects:All Airservices Australia’s Air Traffic Control Line Managers
Status:Adequately addressed

 

General details

Date: 31 Mar 2012 Investigation status: Completed 
Time: 0515 EST Investigation type: Occurrence Investigation 
Location   (show map):near ATMAP (IFR reporting point) Occurrence type:Loss of separation assurance 
State: WA Occurrence class: Airspace 
Release date: 28 Feb 2014 Occurrence category: Incident 
Report status: Final Highest injury level: None 
 

Aircraft 1 details

Aircraft manufacturer: Airbus 
Aircraft model: A330 
Aircraft registration: PK-GPA 
Serial number: 1075 
Operator: Garuda 
Type of operation: Air Transport High Capacity 
Sector: Jet 
Damage to aircraft: Nil 
Departure point:Denpasar, Indonesia
Destination:Melbourne, Victoria

Aircraft 2 details

Aircraft manufacturer: Airbus 
Aircraft model: A330 
Aircraft registration: PK-GPO 
Serial number: 1288 
Operator: Garuda 
Type of operation: Air Transport High Capacity 
Sector: Jet 
Damage to aircraft: Nil 
Departure point:Denpasar, Indonesia
Destination:Sydney, NSW
 
 
 
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Last update 24 June 2014