Systemic investigation of air miss occurrences 1991-1992

The Australian Air Traffic Service (ATS) system provided by the
Civil Aviation Authority (CAA) is responsible for the provision of
a safe, efficient, and cost

effective air traffic control and advisory service to the aviation
industry within domestic and international (oceanic) airspace.

This BASI study conducted during 1992 was aimed at understanding
the organisational factors and system characteristics, and the
underlying failures

which lead to certain ATS occurrences. BASI's endeavour was to
provide the CAA with a method which would allow the cause of a
particular problem to be

tracked to its origin. Thus potential remedial action could be
applied at the source of the problem.