As a result of this investigation, and a number of similar
occurrences, the Bureau of Air Safety Investigation issued a report
(B98/90) of an investigation of systemic issues at the Sydney
Terminal Control Unit. Nine recommendations were made in the
report, the following four of which are considered valid for this
investigation:
"R980157
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
Airservices Australia ensure that adequate refresher training is
undertaken by controllers in order to provide for high levels of
controller proficiency and standardisation and so that the
integrity of safety cases, in which refresher training is deemed to
be a mitigating strategy for identified hazards, is
maintained."
"R980159
Airservices Australia reassess the human factor hazard analysis for
both Stage One and Stage Two of the LTOP 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."
"R980160
Airservices Australia consider restructuring the current roster
operating in the Sydney Terminal Control Unit to ensure that
contemporary fatigue management research is translated into
meaningful duty hour regulations. In any restructure of the roster,
BASI recommends that Airservices Australia expand its absentee
management program to include individuals who expose themselves to
the risks of fatigue by participating in excessive amounts of
overtime and/or emergency duty."