As a result of this investigation, and a number of similar
occurrences, the Bureau of Air Safety Investigation undertook a
systemic investigation into factors underlying air safety
occurrences in Sydney Terminal Area airspace and issued report
B98/90 on 18 August 1998. Nine recommendations were made in the
report; the following three were considered relevant to this
investigation.
R980157
"The Bureau of Air Safety Investigation recommends that Airservices
Australia review the application of the "teams" concept within the
Sydney Terminal Control Unit to ensure that teams are resourced
appropriately and that there is an ongoing commitment to the
provision of adequate training in order to achieve a high level of
controller proficiency and standardisation."
R980158
"The Bureau of Air Safety Investigation recommends that Airservices
Australia ensure that adequate refresher training is undertaken by
controllers in order to provide for high levels of controller
proficiency and standardisation so that the integrity of safety
cases, in which refresher training is deemed to be a mitigating
strategy for identified hazards, is maintained."
R980159
"The Bureau of Air Safety Investigation recommends that Airservices
Australia reassess the human factor hazard analysis for both Stage
One and Stage Two of the Long Term Operating Plan safety cases, so
that the mitigating strategies applied to identified hazards
adequately allow for the fundamental limitations of human
performance. In reassessing this hazard analysis, BASI recommends
that Airservices Australia seek the assistance of human performance
expertise".
The following responses were received from Airservices Australia
on 16 November 1998:
[R980157]
"A recent review of Sydney ATS has resulted in a "spill" of all
management positions and a subsequent recruitment program which
will be completed by 16 November 1998 to coincide with the
Airservices' Business Transformation program.
The first step in this review has been to ensure that the
management structure of the facility can operate effectively and
that appropriate skills are available within the team. The manner
in which the teams operate is the subject of a concurrent review
process.
In support of these reviews, a consultant has completed a wide
ranging review of supervision within air traffic services and its
application within Teams.
Recommendations from these studies will be introduced into the
Sydney rostering committee deliberations examining a better
framework for TCU rosters. Sydney ATS management plan to introduce
a revised roster in the TCU by 1 February 1999.
Team Leader training is recognised as vital to the success of
teams and during October and November all Team Leaders will
complete a series of Human Factors and Team Resource training
modules. To further ensure that Team Leaders are better equipped to
perform their duties a specific training programme for each Team
Leader will be developed by 22 December 1998".
Response classification: CLOSED - ACCEPTED
[R980158] "Airservices provides familiarisation
training in various forms before the introduction of new procedures
and to maintain controller skill levels. This ongoing programme has
been augmented by an additional period of refresher training which
all TCU controllers will undertake during the remainder of this
year".
Response classification: CLOSED - PARTIALLY ACCEPTED
[R980159]
"The LTOP Stage One and Stage Two Safety Cases have been subject to
review by independent experts in the field as well as being the
subject of a number of post implementation reviews. Recommendations
arising from those reviews have been progressively evaluated and
applied as appropriate.
Airservices will consider augmenting its review processes with
human factors expertise in future".
Response classification: OPEN