Saab Aircraft AB SF-340B, VH-XDZ

Local Safety Action

Airservices Australia's Occurrence Investigation Report (V4)
dated 7 May 1999 under the heading of recommendations stated:

"Actions Taken

The officer concerned and his team leader have been interviewed to
obtain their perspective on the occurrence. The officer was
suspended and undertook 2 days of training and assessment by his
team leader.

Other officers on duty at the time of the occurrence have been
counselled to confirm the need for close scrutiny and oversight of
traffic disposition, officer relief and coordinator support.

Actions to be taken.

All Flight Service Officers will be made aware of the findings of
this investigation".

ATSB Safety Action

As a result of this and other occurrences the Australian
Transport Safety Bureau (ATSB) investigated a safety deficiency.
The deficiency was identified as: "Human factor issues in flight
service centres are creating an environment in which safety may be
compromised".

Air Safety Recommendation R19990220 was released to the public
on 27 January 2000 and stated:

"The Australian Transport Safety Bureau (formerly BASI)
recommends that Airservices Australia address flight service
related issues that have the potential to seriously compromise
safety, including those relating to incidents where there was a
"failure to pass traffic" or a "failure to
coordinate."

Air Safety Recommendation R19990220 was formally rejected by
Airservices Australia in their response dated 28 February 2000. The
ATSB considered the Airservices' rejection and because of
developments with another "failure to pass traffic" occurrence
asked "whether Airservices' rejection of the recommendation
stands".

Airservices Australia confirmed their formal rejection of
R19990220 on 29 March 2000. The rejection was considered by the
ATSB and, due to the subsequent closure of the Flight Service
Centres, categorised the response as "Closed - Not Accepted".

The flight service officer did not provide directed traffic
information to the crew of VH-XDZ about the disposition of
VH-XDA.
The workstation design complicated traffic management, the
maintenance of an accurate air picture, and oversight of the flight
service officer's workload.
The absence of three staff on sick leave.
Management of the flight service officer was inadequate by
allowing the officer to continue working for long periods, with a
high workload, without satisfactory supervision.
Management of the flight service centre roster did not provide
properly endorsed and rested staff to provide an effective flight
service function

The incident occurred during a high workload period for the
flight service officer. Analysis of the audio transmissions
revealed frequency congestion, with multiple calls from aircraft
and associated inter-unit coordination. The officer may have been
suffering the effects of fatigue having worked unexpected periods
of overtime on the preceding days, as well as concern stemming from
the meeting held earlier during the day. The imminent closure of
the flight service function had lessened motivation and morale and
heightened general levels of uncertainty and anxiety. The
detrimental impact of excessive anxiety, stress and high workloads
on human performance has been well documented. These factors appear
to have had a significantly adverse influence on the flight service
officer's ability to perform effectively.

The console needed a large chart display on a mobile trolley
placed at 90 degrees to the operating position to complement the
overhead map display. The arrangement of this workstation was
ergonomically undesirable, requiring the flight service officer to
continually change physical position to correlate the flight
progress strip display with the chart display. Moreover, the chart
display was a physical barrier between the operating position and
the supervisor/utility position. This barrier may have prevented
the evening shift officer from noting the flight service officer's
increasing workload.

The number of active flight progress strips for aircraft
movements within the flight service officer's area of
responsibility was considerable. Because the geographical display
bays were not used and the strips were sequenced in chronological
order, this adversely affected the situational awareness on the
flight service officer

The crew of VH-XDZ, a SAAB 340 operating an IFR category flight
taxiing at Mt Isa was not passed traffic information on VH-XDA,
another SAAB 340 operating an IFR flight inbound to Mt Isa on the
same track to be used by the departing aircraft. The flight service
officer was not aware of this omission until the aircraft had
passed in flight at 1750 EST.

The incident occurred during a peak in traffic movements, with
multiple transmissions from aircraft on both VHF and HF frequencies
in airspace that encompassed a large and complex geographical area.
The work position comprised 2 HF networks, each with three
frequencies, as well as four VHF repeaters. Because of the size and
complexity of the airspace, the console needed a large chart
display on a mobile trolley placed at 90 degrees to the console
operator's position to supplement the overhead map display. The
flight service officer reportedly had about 15-18 active flight
progress strips for aircraft movements within his area of
responsibility at the time of the occurrence and 12 aircraft on
frequency. Geographical display bays were not used for the flight
progress strips; they were sequenced in a chronological order.

The flight service officer had been on duty for five hours
before the incident and had worked the position for most of that
time. During the previous three days, the officer had worked a
10-hour shift, a 7-hour shift and a 9.5-hour shift, none of which
agreed with the planned roster. Staffing throughout the day of the
occurrence had been difficult as three staff were on sick
leave.

Team leader coverage was required in the centre between the
hours of 0600 and 2000 daily. The sole team leader available for
duty on the day of the occurrence had worked from 0700 to 1700
hours and was required to stand-down because 10 hours was the
maximum shift length allowable. A relief team leader was not
available.

The flight service officer elected not to ask for support during
the increased workload because of staff availability. Three other
flight service officers were on duty. One was absent from the
centre preparing a meal; one was working the FIS 3 position; and,
the evening shift officer was eating a meal at the utility
position. The evening shift officer intended to provide relief at
one of the two consoles and had completed a 7-hour night shift
earlier that morning.

Earlier that day, all flight service officers on duty at the
Brisbane centre were briefed at a meeting on the imminent closure
of the flight service function and the potential ending of their
employment with Airservices Australia.