Output Number
Approval Date
Organisation
Australian Defence Force
Published Date Time
Recommendation type
Mode
Date released

Interim Recommendation

The Australian Transport Safety Bureau (formerly BASI)
recommends that the Australian Defence Force review Inflight
Emergency Response (IFER) training for air traffic services staff
responsible for the provision of services to civil aircraft.

Organisation Response
Date Received
Organisation
Australian Defence Force
Response Text

I have ordered a review of IFER training, procedures and
practices within Defence. The review which is being conducted by
the Directorate of Flying Safety (DFS-ADF), will involve all
operational ATC elements, our trainimng system and ATC rating and
checking mechanisms. Further action will be contingent on any
recommendations flowing from this review and the associated report,
due for completion by 29 February 2000."



ATSB Note: On 7 April, CAF advised (by phone) that:



In response to the ATSB Interim Recommendation IR19990190, a review
of IFER training within Defence has been completed and the
implementation of recommendations is underway.

Date Received
Organisation
Australian Defence Force
Response Text

1. I am writing to advise you of the progress of implementation
of the recommendations arising from the Defence IFER policy and
procedures review. This advice is in response to a verbal request
from your office, and to assist in the closure of the final report
into Air Safety Occurrence Report 199904842.



2. The following actions have been taken:



a. The RAAF School of Air Traffic Control has incorporated 'Duty of
Care' into all courses.



b. Operational evaluations are conducted at every ATC unit by a
Headquarters No 41 Wing standardisation team. This team now
specifically assesses controllers' theory knowledge of IFER (closed
book oral examination), and tests each approach-rated controller in
an IFER scenario during evaluation. Every ATC unit has conducted
IFER briefs, raising IFER awareness significantly. All controllers
checked so far by the standardisation team have demonstrated an
appropriate level of knowledge.



c. Dedicated Senior Training Officer (STO) positions have recently
been established for each ATC unit. Unfortunately, current staffing
levels will dictate STO duties continue to be a secondary
appointment for some time.



d. Every endeavour is being made to allow nominated STOs adequate
time to establish/maintain quality programs.



e. A temporary instruction has been forwarded to all units
requiring STO qualification to include completion of the RAAF
Training Development Officer Course. A formal amendment to AAP
8132.003 is currently being drafted.



f. Standard training guides for each control element are in the
process of being developed.



g. Development of a formal Supervisor Course is under way and is
expected to be completed in November 2000.



h. All operational controllers have received instruction on Chapter
11 of the Airservices IFER training manual.



i. The Manual of Air Traffic Services (MATS) amendment protocol has
been amended to require Air Force Headquarters sign-off of all
amendments.



j. A revised IFER Checklist has been completed and will shortly be
distributed following printing.



k. A draft civil/military IFER manual has been developed and is
under editorial review by both Airservices Australia and
Defence.

Date Received
Organisation
Australian Defence Force
Response Text

...the review concluded that Defence IFER management and
training is capable of improvement. Consequently, the following
recommendations have been endorsed:



a. The School of Air Traffic Control (SATC) is to introduce "Duty
of Care" guidance to all ATC training, as well as additional IFER
training scenarios into simulator sequences.



b. No 41 Wing, with the assistance of SATC, is to develop core ATC
field training requirements to ensure all controllers are receiving
comprehensive initial IFER training and appropriate annual
training.



c. No 41 Wing, is to establish dedicated Senior Training Officer
(STO) positions within ATC flights.



d. Pending the resolution of issues associated with establishing
the extra positions needed across Air Force to handle the Senior
Training Officer role, No 41 Wing is to ensure that incumbent STOs
are provided adequate time to establish/maintain quality training
programs.



e. The Manual of Air Traffic Organisation and Administration (AAP
8132.003) is to be amended to require that all STOs complete the
RAAF Training Development Officer Course. No 41 Wing is to cycle
all current STOs through this course.



f. SATC, in consultation with No 41 Wing, is to develop and
maintain a standard ATC Flight Training Guide. This Guide is to
form the basis for individual base training guides, modified as
necessary by the STO to suit local conditions.



g. SATC, in consultation with No 41 Wing, is to develop a formal
Supervisors Course that includes as a minimum, IFER and team/crew
resource management instruction.



h. No 41 Wing is to ensure that all operational controllers have
received adequate instruction on Chapter 11 of the Airservices IFER
Training Manual, which is being used as an interim guide.



i. The Air Force Headquarters Deputy Director-Air Traffic Services
is to ensure that amendment processes for the Manual of Air Traffic
Services meet Defence requirements.



j. No 41 Wing is to sponsor the development of an IFER manual and
Checklist. The initial recommendation was that the publication
could be either Defence-only or joint civil/military. Subsequent to
Defence approaching Airservices, agreement has been reached to
develop a joint manual that will also include military-specific
emergencies."



k. The Air Force Headquarters Deputy Director - Air Traffic
Services is to raise a request for National JETSCARE information to
be included in the appropriate Defence publications. Defence was
unaware of the JETSCARE contact and associated procedures.



As you can appreciate, not all of the recommendations are specific
to IFER. This is because the review terms of reference allowed for
wide-ranging coverage of safety issues related to ATC training and
operation. While the prime focus was to address the ATSB Interim
Recommendation, Defence decided to give the review team a brief
that allowed discretion to examine other safety related issues.
Consequently, some of the recommendations address broader
organisational matters than just the issue of IFER
management.



The recommendations have either been implemented or are in the
process of being actioned, given that some tasks lend themselves to
early completion while others, such as the Manual, require longer
lead times. Notwithstanding, I have directed that all actions be
completed by 30 June 2000 with formal notification to this
Headquarters.

Output Number
Approval Date
Organisation
TransAdelaide
Published Date Time
Recommendation type
Mode
Date released
Background Text

Occurrence No: 2006003

Occurrence Date: 28 March 2006

BACKGROUND

At approximately 0700 on 28 March 2006, TransAdelaide train H307
passed signal 161 at Adelaide Station while displaying a red
indication.

The investigation team has been advised that train H307 was
positioned approximately 15 to 20 metres from signal 161 in
preparation for departure from Adelaide Station. In accordance with
TransAdelaide departure procedures, a Platform Coordinator was
positioned approximately 10 metres in front of the railcar to give
a "Starting" hand signal. The driver of train H307 then departed
the platform; however train H307passed signal 161 while a red
indication was displayed.

ANALYSIS

During early stages of the investigation the Australian
Transport Safety Bureau (ATSB) gathered evidence suggesting that a
number of factors contributed to train H307 passing signal 161
while displaying a red indication.

TransAdelaide's "Common General Operating Rules" (dated 22
November 2000) defines the "Starting" hand signal (i.e. guard's
signal to driver to start train) in rule 43(k). This rule states
that therequired signal is a "Green light waved above the
head…"
. However, the investigation has been advised that
Platform Coordinators indicate a "Starting" hand signal using a
steady green light held by an outreached horizontal arm. A steady
green light is defined in rule 43(m) as an "All clear or
proceed"
signal which is equivalent to a clear or proceed line
side signal.

In addition to hand signalling methods that are inconsistent
with operating rules, it is likely that the position of the
Platform Coordinator and the outreached arm may have obscured, or
partially obscured, signal 161. Under these conditions it is
possible that the driver of train H307 only observed a green light
before departing the platform.

The ATSB is continuing its investigation.  However, in view
of the evidence to hand the ATSB has made the following interim
recommendation under section 25 of the Transport Safety
Investigation Act 2003. Please note that this interim
recommendation in no way prejudges the final conclusions that may
be reached in the ATSB's final report into this accident.

Interim Recommendation IR20060009

The ATSB recommends that TransAdelaide:

  • Review the departure procedures for Adelaide Station to ensure
    that Platform Coordinators provide railcar drivers with clear,
    unambiguous "Starting" signals, consistent with TransAdelaide's
    "Common General Operating Rules".
  • Ensure that hand signals do not obscure a driver's view of line
    side signals.