Airbus Industrie A320-211, VH-HYD

Investigation number

199700052

Occurrence date

05/01/1997

Location

6 km SSE Sydney Airport

Report release date

23/07/1999

Report status

Final

Investigation type

Occurrence Investigation

Investigation status

Completed

Occurrence class

Incident

Highest injury level

None

Factual Information Safety Action Significant Factors Analysis Summary

History of SODPROPS

The Civil Aviation Safety Authority (CASA) adapted a US Federal
Aviation Administration (FAA) air traffic control spacing and
sequencing standard (FAA 7110.65J) and incorporated it into the
CASA Manual of Operational Standards in November 1994. The FAA
standard was used by the Parallel Runway Standards Evaluation Group
to develop a procedure for Australian use. This group comprised
regulatory and air traffic services elements of the then Civil
Aviation Authority along with other members of the aviation
industry. The FAA standard was modified by adding a requirement
that the departure runway course must diverge 15 degrees away from
the approach course to the opposite direction runway.

The modified FAA standard was introduced into service at Sydney
airport together with other changes identified as being able to
meet government policies in relation to operations and noise
abatement procedures at that airport. Airservices, which was
responsible for Australian airspace management from 1 July 1995,
planned to commence SODPROPS on 19 October 1996. Officers from
Airservices organised an industry seminar for 26 September 1996 to
discuss the proposed new traffic management procedures associated
with SODPROPS and with the use of runway 34R for departures. At
this seminar several participants questioned the extent of risk
analysis that had been conducted to ensure that SODPROPS provided
adequate levels of safety during all operations.

On 10 October 1996, a senior officer from Airservices wrote to
CASA, seeking confirmation that the standard governing the use of
SODPROPS was available for use without impediments to its
application. In response to this query, a senior CASA officer
replied that there was no impediment to the use of the standard,
but reminded Airservices that "the safety and change management
standards for Airservices require you to analyse the risks
associated with the changes to ensure that unacceptable hazards are
eliminated before the change is completed".

During a meeting with CASA representatives on 15 October 1996,
senior Airservices officers advised that "it [Airservices] had
completed a formal change process, including safety analysis,
hazard analysis, training, etc. and that all risks had had
correction procedures put in place".

On 17 October 1996, an Airservices officer from Sydney wrote to
a domestic operator and supplied details of risk analysis conducted
for the implementation of SODPROPS. This letter advised that the
following three risk categories had been examined:

- "approach track keeping and associated flight crew or
ATC blunders";

- "departure procedure compliance, engine failure or other
aircraft malfunction on take-off, or flight crew/ATC blunders";
and

- "Air Traffic Management risk".

Departures from runway 34R and SODPROPS both commenced on 19
October 1996.

SODPROPS risk analysis

Section 6.3 of the Legislative Instrument Proposal (LIP) for the
Safety Regulation of Airservices Australia specifically detailed
the manner in which Airservices was required by CASA to control and
manage changes to systems, equipment or procedures to ensure that
unacceptable hazards were eliminated by the time the change was
completed. The BASI investigation found no evidence that the
requirements of this section had been complied with. One form of
risk analysis methodology mentioned in the LIP as being acceptable
was "assessment of overseas experience..". Claims by Airservices
that airspace managers at various overseas airports utilised
procedures similar to SODPROPS, were not substantiated. Although
the BASI team discovered several examples of international,
opposite-direction, parallel runway operations, these were not
regarded as sufficiently similar to the Sydney operation to be used
as justification in the risk analysis.

The risk analysis provided to the domestic operator, with a
matrix of data, suggested that a form of quantitative modelling had
been conducted using a narrow set of data. The assumptions for the
modelling were not analysed and the model itself was not validated
as required in the LIP.

The BASI investigators were supplied with the same matrix of
data when Airservices officers were asked to supply full details of
the risk analysis associated with the introduction of SODPROPS.

Additionally, there was no record available to the investigation
team to indicate that CASA or the Parallel Runway Standards
Evaluation Group had conducted any significant analysis of the
risks associated with the development and adoption of the SODPROPS
standard for Australian use.

Recommendations

As a result of the investigation into this occurrence, the
Bureau of Air Safety Investigation issued the following
recommendations:

IR970014

"The Bureau of Air Safety Investigation recommends that
Airservices Australia review the requirements detailed in AIP
Supplement H73/96, (10 October 1996) Simultaneous Opposite
Direction Parallel Runway Operations Sydney (KSA) and:

develop a SID which incorporates a standard left hand turn
after takeoff, and tracks the departing aircraft through the heads
of Botany Bay in accordance with accepted separation and
noise-abatement procedures,

have the departing aircraft remain on tower frequency until the
assigned turn has been completed, and

develop a pilot aid for inclusion in departure and approach
procedures (DAP) East. This chart should depict the expected flight
path of aircraft departing and arriving under SODPROPS, and could
be similar to the pilot-aid (Issue 1, 14 September 1995), located
in DAP East, advising pilots about independent visual approaches at
Sydney Airport."

Response from Airservices Australia received 4 March 1997:

"BASI has made three recommendations arising from Occurrence
9700052

Airservices has recently conducted a post implementation review
(PIR) into SODPROPS at Sydney. Specific action undertaken by
Airservices to address the BASI recommendations is as follows:

An appropriate SID will be developed which will be standard for
all departures from Rwy 16L (not specific to SODPROPS). Until then
the RADAR 6 departure with specific headings will continue to be
used.

The BOTANY BAY HEADS Visual departure is no longer considered
practical for jet aircraft owing to the difficulty in navigating to
the Heads with high body angles and the possibility of entering
cloud above 3000 feet prior to reaching the Heads.

An instruction has been issued requiring ADCs to instruct
departing aircraft under SODPROPS to remain on Tower frequency
until established in the appropriate left turn.

The recommendation to produce a pilot aid for inclusion into
DAP (East) has been referred to CASA Flying Operations Branch for
consideration/action.

While supporting these recommendations, Airservices is concerned
that the report does not address the principle causal factor of the
occurrence, namely flight crew error.

No reference is made to the following factors:

The assigned heading was correctly read back by the pilot but
not entered into the FMS;

The pilot called departures radar at the appropriate time but
failed to read back the assigned heading;

The use of FMS below the LSALT."

Response classification: Closed-Accepted

Response received from the Civil Aviation Safety Authority 22
April 1997:

"I refer to BASI Interim Recommendation IR 970014
addressed to Airservices Australia concerning Simultaneous Opposite
Direction Parallel Runway Operations (SODPROPS) at KSA Sydney. The
following comments are provided from a CASA perspective.

The first point of the recommendation is that "a SID be
developed which incorporates a standard left hand turn after
take-off and tracks through the heads of Botany Bay in accordance
with accepted separation and noise abatement procedures". The
SODPROPS standard is a visual standard and obviously the last line
in separation would be the visual element. The ATC procedures
specified in the local instruction indicated that a Botany Bay
visual departure should be issued to departing aircraft. CASA
believes there is no point in developing a Standard Instrument
Departure (SID) for a visual procedure, in fact it could stop
pilots from looking outside.

The second point is that the departing aircraft should remain on
the tower frequency until the departure turn has been completed.
Airservices Australia have since implemented this.

Finally, it is recommended that a pilot aid on SODPROPS be
developed. This is probably worthy of consideration but CASA
believes that AIP SUP H73/96 may require amending to specifically
indicate a section on departing aircraft. Other than a reference in
the standard section to course divergence there is no specific
indication regarding aircraft departure requirements."

Response classification: Closed-Accepted

R970150

"The Bureau of Air Safety Investigation recommends that
Airservices Australia conduct a comprehensive systems safety
analysis of simultaneous opposite direction parallel runway
operations (SODPROPS)."

The Bureau also made the following recommendation (R970151) to
the Civil Aviation Safety Authority:

"The Bureau of Air Safety Investigation recommends that
the Civil Aviation Safety Authority review the Operational Standard
"Simultaneous Opposite Direction Operations" to ensure that it
provides an acceptable level of safety."

Response received from Airservices Australia 1 December
1997:

"I am writing in response to your occurrence report and
the associated recommendation that Airservices "conduct a
comprehensive systems safety analysis of simultaneous opposite
direction parallel runway operations (SODPROPS).

In addressing this recommendation, I commissioned a team to
conduct an independent analysis of the SODPROPS procedure itself
and the analysis that was conducted prior to the implementation of
the procedure at Sydney Airport. This team comprised
representatives from ATS' Safety and Quality Management Branch,
[and] ATC specialists from Sydney and Brisbane. The team was
assisted by expert support from CASA and the major domestic
airlines.

In essence, the analysis team has produced a Safety Case (copy
enclosed) addressing the safety issues identified by the original
SODPROPS implementation team. This Safety Case has been augmented
by a Fault Tree Analysis of the risk of failure of the SODPROPS
procedure.

I must emphasise that the bulk of the analysis presented in the
SODPROPS Safety Case reflects the extensive hazard analysis and
risk mitigation work that was done by the implementation team prior
to the implementation of SODPROPS.

Whilst it can be said that the data was not collated into a
concise document (for which CASA and Airservices now advocate a
Safety Case), the data was available in relevant files within the
Sydney management system at the time of the BASI investigation.

The data used in this report was available in relevant files
within the Sydney management system at the time of the BASI
investigation.

The Fault Tree Analysis was compiled using probability data on
human performance and on historical incident data. The SODPROPS
Safety Case provides the necessary assurance that SODPROPS is being
operated at an acceptable level of safety."

Response classification: Open

R970151

"The Bureau of Air Safety Investigation recommends that
the Civil Aviation Safety Authority review the Operational Standard
"Simultaneous Opposite Direction Operations" to ensure that it
provides an acceptable level of safety."

The Bureau also made the following recommendation (R970150) to
Airservices Australia:

"The Bureau of Air Safety Investigation recommends that
Airservices Australia conduct a comprehensive systems safety
analysis of simultaneous opposite direction parallel runway
operations (SODPROPS)."

Response received from the Civil Aviation Safety Authority 27
November 1997:

"I refer to your letter dated 1 October 1997 reference
BS/970061 regarding Recommendation R970151.

CASA has reviewed the Operational Standard "Simultaneous
Opposite Direction Operations" as you have recommended. Following
Occurrence 9700052 on 5 January 1997 the instructions in AIP OPS
paragraph 19.4 were changed by NOTAM to require pilots to remain on
Tower frequency until instructed to change, thus enabling Tower to
correct the kind of confusion evident during the occurrence. The
amendment will be correctly inserted into the AIP OPS text by AIP
Amendment List 20, effective 4 December 1997.

Given the change to procedures our conclusion is that the
standard expressed in the CASA Manual of Operational Standards
(MOS) Part 3 Chapter 5.9 is adequate.

The MOS standard will be further reviewed in the light of any
study which may be undertaken by Airservices in response to your
recommendation R970150."

Response classification: Open

Following the provision of the SODPROPS safety case the Bureau
elected to have the document reviewed by an independent consultant
with international experience in aviation risk management practices
and procedures. The intent of the review was to ascertain whether
the safety case undertaken by Airservices was a comprehensive
safety case and whether it had adequately demonstrated that
SODPROPS could be conducted at a reasonable level of safety.

The review of the safety case was conducted in the last week of
March 1998. On receipt of the consultant's report it will be
reviewed and any further action by the Bureau will be subject to
the findings of the report.

The crew of the A320 set an incorrect heading into the FCU as
they were turning onto the runway. They had discussed the need to
turn left after takeoff and had correctly read back to the
aerodrome controller the radar heading for this turn after takeoff.
Both pilots had followed the company procedures required for
setting the departure heading into the FCU, but the cross-check
process did not detect the incorrect heading that had been set. It
is possible that the training situation in the cockpit, lack of
familiarity with the procedure, and the action of setting the
heading whilst turning onto the runway had prevented the pilots
from recognising that the heading they had set in the FCU was, in
fact, the runway heading.

The aerodrome controller was unable to resolve the situation
because when he determined that the A320 had not turned left, the
A320 crew had already transferred to the Departures (S) frequency.
Had the A320 crew remained on the tower frequency until established
on the assigned departure heading, the controller would have been
able to immediately instruct the crew to turn onto the correct
heading.

The SODPROPS procedure was introduced to the Sydney Airport
environment with neither the regulator nor the airservice provider
having adequately analysed the risks associated with the
implementation of the standard. CASA did not critically examine how
the standard was developed by the FAA and did not determine if any
restrictions were applied when the standard was utilised in the
USA. Furthermore, CASA did not determine the extent to which this
standard was used in other countries where the regulators'
experience might have been able to influence the standard's
development for use in Australia.

Although Airservices had agreed to comply with the requirements
of the LIP until the document was signed into law by the Minister,
the evidence indicated that the requirements for risk analysis of
new procedures in the LIP were not complied with prior to the
introduction of SODPROPS.

Airservices commenced the consultation process with industry
less than 4 weeks prior to the planned implementation of the
procedure. This period did not give the industry sufficient time to
consider the procedure, or to develop and distribute internal
procedures that incorporated the new operation. Because industry
representatives were provided with details of the risk analysis 2
days before the operation was due to start, there was insufficient
time for industry analysis of those details.

Simultaneous opposite-direction parallel runway operations
(SODPROPS) were being used at Kingsford-Smith Airport (KSA) Sydney.
An Airbus Industrie A320 aircraft was departing towards the south
from runway 16L and an international Boeing 747 (B747) was tracking
towards the north, established on final approach for runway 34L.
The A320 aircraft was crewed by two pilots, with the manipulating
pilot seated on the right side undergoing training to be a training
pilot. Only one of the pilots had previously flown the SODPROPS
procedure but during the departure briefing, the pilots discussed
the requirement to turn left after takeoff.

The SODPROPS procedures were carried out by the aerodrome
controllers in accordance with the Sydney District Office local
instructions approved by Airservices Australia (Airservices), with
the exception that the A320 crew was assigned a radar departure
with an initial left turn onto 115 degrees instead of the preferred
BOTANY BAY HEADS ONE Visual Departure procedure. The crew
mistakenly dialled 155 degrees into the aircraft's flight control
unit (FCU) on the glareshield as the aircraft lined up on the
runway, but correctly acknowledged to air traffic control (ATC) the
assigned heading of 115 degrees.

After takeoff, when the crew selected the heading mode on the
FCU, they realised that they had set an incorrect heading and
maintained runway heading (155 degrees). The aerodrome controller
saw that the A320 did not turn left as instructed, but as the crew
had already transferred to the departures south (Departures (S))
frequency, he was not able to instruct them to turn left onto the
correct heading. When communications were established with
Departures (S), that controller directed the crew to turn left to
115 degrees. The A320 crew reported that they had the arriving B747
in sight at all times, but the crew of the B747 did not sight the
A320.

The aircraft did not breach the separation standard for the
SODPROPS approach.

Aircraft Details

Model

A320

Registration

VH-HYD

Serial number

025

Operation type

Air Transport High Capacity

Departure point

Sydney, NSW

Departure time

0630 hours ESuT

Destination

Melbourne, VIC

Damage

Nil