Airservices Australia has conducted a review of all of the
issues related to the Launceston incident including those issues
specifically sighted in the ATSB recommendation. The observations,
initiatives and recommendations listed below have been fully
discussed with CASA and the NASIG, and we are currently working to
ensure implementation is properly coordinated.
As a part of our normal risk monitoring processes, reports from
electronically submitted incident and event reports are
continuously reviewed. The information, available up until 17
February 2004 indicates that 60 (6.5%) of all reported incidents
(915) can be assessed as relating to the changes made on 27
November 2003. Of these 60 incidents 81.6% are pilot attributable
with the main factors either being pilots failing to comply with
the new changes or violating controlled airspace. This data has
shown that pilot education and training has not been as effective
as it was expected to be.
The ATSB Report also highlighted a possible misunderstanding by
pilots of the intent of the pilot education and training.
Airservices proposes the following strategies to address the issues
concerning pilot education and training:
(a) That CASA conduct a quality assurance assessment of the pilot
training and education as well as pilot comprehension of the
material. Confirmation that pilots correctly understand the
published material, especially the general aviation segment, is
important to the safe operation of the airways system; and
(b) That further pilot education be developed with a particular
re-emphasis on requiring pilots to:
(i) Monitor the most appropriate frequency to assist in situational
awareness;
(ii) Make radio contact with flights considered to be in potential
conflict to assist in situational awareness;
(iii) Comply with the need for transponder carriage, use
serviceability; and
(iv) Recognise that the more flexible procedures and airspace
introduced on 27 November 2003 places additional responsibility on
pilots and that the ongoing safety of the system requires that they
comply and understand the requirements which permit this additional
flexibility. CASA was advised of these pilot training and education
strategies on 16 January 2004, and subject to their agreement, CASA
would be responsible for implementation.
The review of incident data and the ATSB Report also raised an
issue of pilot situational awareness, especially within Class E
airspace. Transponder non-usage and/or unserviceability has also
been a noticeable trend and can be associated with the situational
awareness issue. Immediate strategies that address this issue are
as follows:
(a) To assist pilots to choose the most appropriate frequency and
assist them in gaining situational awareness, a frequency planning
chart will be published depicting enroute frequencies in Class G
and Class E airspace. This is an interim chart until the normal
charting cycle takes affect and will be published and distributed
within the next month.
(b) That information be issued to air traffic controllers
reiterating the importance of their radio broadcasts as these
broadcasts also provide situational awareness to aircraft. This
information has been published and took effect on 1.9 January
2004.
(c) That procedures be developed and promulgated that require
pilots, that have unserviceable transponders, to have them repaired
as soon as practicable following notification by ATC of
unserviceability. Again this strategy will require agreement with
and subsequent implementation by CASA.
Further work is also continuing on rectifying a design issue with
the control area steps to the north east of Launceston. The current
design can contribute to a steeper than normal descent
profile.
CASA were advised of these further strategies on 16 January
2004.
The NASIG were advised of all of the above mentioned strategies at
a meeting held on 23 January 2004 and again at a meeting with the
NASIG and [name deleted by ATSB], of DOTARS, on 19 February
2004.
These strategies will be implemented as soon as practicable with
consultation and agreement, where necessary, with the relevant
agencies.
