Airservices Australia should note the safety deficiencies
detailed by this document and take appropriate action.
Review of Aireservices Australia's: Team Operations in Air
Traffic Control and Flight Service
EXECUTIVE SUMMARY (refer to BS/960115 for full report)
A 'teams' approach to staffing was introduced to Air Traffic
Services in the early 1990s by the then Civil Aviation Authority
following from the recommendations of the 1987 and 1992 reviews of
the Air Traffic Services System. Airservices Australia has
subsequently refined the teams concept and the role of the team
leader.
The teams approach has been examined by internal reviews such as
the Review of Team Operations in Air Traffic Control and Flight
Service (March 1992), the Teams Implementation Review (January
1994), and an as yet unpublished review which was conducted in
July-August 1996.
The reviews found that some of the benefits envisioned for teams
such as greater satisfaction with work schedules and improved
standardisation of control techniques, were being achieved at some
locations but also noted that certain difficulties were being
experienced.
During 1996 and early 1997, several incidents associated with air
traffic controller performance were investigated by the Bureau of
Air Safety Investigation. During many of these investigations,
potential safety issues associated with the operation of a teams
approach were identified.
As a result of these incidents, further investigation was
conducted which involved interviewing the members of the 1996
review team as well as several managers, team leaders, human
resource personnel, and safety and quality management
personnel.
This report contains an analysis of the further investigation and
lists a series of identified deficiencies. The report contains
Safety Advisory notice SAN 970137, which is addressed to
Airservices Australia.
Airservices Australia should note the safety deficiencies
detailed by this document and take appropriate action.
RE:SAN970137
Thank you for providing the report on your "Review of
Airservices Australia's Team Operations in Air Traffic Control and
Flight Service".
I am writing to provide comment on the report and the Safety
Deficiencies identified therein.
The report is disappointing in that it generalises the issues
and does not provide objective evidence to support these
generalisations.
The identified Safety Deficiencies reflect this generalistic
flavour and would appear to be a reflection of the author's views
supported only by a select sample of incident reports.
The following commentary on the Safety Deficiencies will
demonstrate my concerns:
1.an undesirably low level of operational support being provided
by experienced controllers, including team leaders and other full
performance controllers, to controllers working in operational
positions.
The team concept, introduced as the report acknowledges, was
introduced in the early 1990s to address concerns expressed in a
report compiled by Dr [name supplied] in 1987.
Teams were seen as a method of providing an appropriate level of
operational support and, more importantly, an ongoing mentoring
capability. The previous management structure was considered
inappropriate in that supervision was too far removed from the
day-to-day operational workface.
The team concept has brought a level of supervision and support
directly to the workface generally on a continuous basis.
The decision to require Team Leaders to perform administrative
functions is a management prerogative requiring the team to be self
sufficient to a certain extent. It is the Team Leader's
responsibility to manage this situation whilst maintaining their
own operational efficiency.
The deficiency noted that there was "an undesirably low level of
operational support ..." without providing any objective evidence
to either indicate what an acceptable level is or to justify such a
broad generalisation.
The report states however that some of the benefits of the team
concept are "co-operation between controllers, a greater degree of
support from other team members, better access to management and
improved standardisation".
The sample incidents quoted in the appendix provide some
examples of occasions when controllers operating autonomously made
errors but in those instances there is no evidence that direct
supervision would have averted the situation.
ATC by its very nature is a cognitive exercise requiring much of
the planning and delivery to be done by an individual. Often
outside input is more a distraction than an assistance.
The examples provided in most cases do not indicate traffic
levels nor just what a supervisor might have done in the instance.
In other examples, controllers were actually being supervised in a
check situation and the incident still occurred.
The report acknowledges that "The provision of direct
supervision or monitoring on a one-to-one basis would be
impractical ... "
The Team Leaders role is quite clearly to provide support and to
monitor the ongoing delivery of the service to ensure its smooth
running and to address the peaks and troughs in activity.
In fact the report acknowledges steps already taken to increase
the support provided - "Initial indications are that these types of
changes have led to an increase in the amount of operational
support being provided.
On some occasions, the Team Leaders ability to always provide
this level of support may be compromised by circumstances, but to
over-react by increasing their presence may well prove to be
counter-productive.
2.an inappropriately low level of emphasis on team development
activities, such as the provision of team leader training and
support, and the regular provision of team days with structured
learning content for team members.
The report refers to 'a recent series of interviews" which
consistently identified the lack of appropriate team leader
training.
Volume 5 of the Safety & Quality Management System
(S&QMS) manuals details at page 11-10 the requirements for the
"Personal Development to Team Leader". This clearly states that the
prospective Team Leader must "successfully complete the approved
training modules for Team Leader development".
Note 3 on that page states that a person may be utilised as a
Team Leader after completion of the Team Leader modules.
The revised Group structures introduced initially in Brisbane
are aimed at providing a greater level of support to the
operational Team Leader thus freeing up more time for them to
concentrate on the support functions for their teams. This is
acknowledged in the report - "Initial indications are that these
types of changes have led to an increase in the amount of
operational support being provided.
The statement that a lack of "the regular provision of team days
with structured learning content for team members" is a safety
deficiency appears to belie the statement in the report that "Most
functional areas and groups now have regular team meetings in which
team development activities do occur. These team meetings are very
well received and provide good developmental opportunities".
Training for elements such as the introduction of TCAS and new
procedures has for some time been delivered in team meeting
environments.
Additionally, ATS now requires teams to conduct structured
refresher training exercises during team days.
It is acknowledged that TAAATS training has impacted upon the
provision of team meetings, however, the merits of providing this
training far outweiqhs any negative effect.
3.performance evaluation systems for team leaders that do not
ensure that relevant team leader performance areas are measured,
and also do not ensure that any degradation in a team leader's
proficiency on operational positions will be detected.
This is an acknowledged area of concern, in fact the whole
assessment methodology for Air Traffic Controllers is the subject
of a research program being conducted by the University of
Queensland in co-operation with Airservices.
The intention is the all air traffic controllers within a
stream, including Team Leaders, will be subject to the same scaled
assessment of proficiency against identified elements of
competency.
The project is scheduled for completion in 1998 and will provide
a more contemporary assessment model based on validated competency
requirements.
Ongoing evaluation of a Team Leader's performance or proficiency
relies, on a day-to-day basis, on the Team Leader who has been
selected on the basis of an extensive knowledge of the functional
area. The Team Leader modules provide an awareness of the
proficiency requirements and the pitfalls of inappropriate
utilisation of skills.
It should be noted that the traditional checking methodology for
all Air Traffic Controllers required only one "over-the-shoulder"
check every six months.
4.an inappropriately low level of training and development for
many controllers on human factors issues, particularly those
associated with inter-controller co-ordination and
communication.
This deficiency is acknowledged and is being addressed through
ab initio training and in the comprehensive training package being
delivered prior to transitioning to TAAATS.
The report acknowledges these measures but comments that "the
extent to which this training program will increase controller's
human factors knowledge cannot be determined at this stage". Surely
if the effect cannot be measured the statement that the level of
training is "inappropriately low, is at the very least
pre-emptive.
Additionally, the claim that issues related to "inter-controller
co-ordination and communication" are of concern is contrary to the
statement that "inter-controller co-ordination and communication
are generally performed well in many functional areas".
Whilst accepting that there are instances of deficiencies in
this area demonstrated in the appendix, the safety deficiency is
far too general in its implication.
The report provides information on the benefits of "Controller
Resource Management" analogous with the more traditional Crew
Resource Management applied by most airlines.
The benefits of this philosophy are accepted and I would say
form the basis of Airservices' original decision to adopt the teams
concept. The Team Leader has the responsibility to manage his
resources in the most efficient and effective manner possible in
any given circumstance.
The introduction of TAAATS may well "reinforce the
single-operator nature of Australian air traffic control systems",
however, TAAATS introduces a comprehensive array of alerting tools
and prompts, not evident in the current system, to assist the
operator in provision of the air traffic control.
It should be noted that many countries in the world are also
looking to automation of air traffic control as the means of
increasing the efficiency of the service. Associated with this
there are moves towards greater autonomy in the cockpit (free
flight) and less controller intervention.
Adoption of this philosophy may well result in fewer controllers
and less active supervision in the future.
In conclusion, Airservices will continue to review and refine
its management philosophy and the application of that
philosophy.
Thankyou for providing your response to Safety Advisory Notice
(SAN) 970137, arising from the Bureau's review of Airservices
Australia Team Operations in Air Traffic Control and Flight
Services.
Your comments regarding the generalised nature of the report are
noted. The Bureau would like to point out that a Safety Advisory
Notice, by its very nature, may indeed be generalised, as the
evidence upon which it is based may be somewhat limited or
anecdotal. Alternatively, the safety impact of the safety
deficiency under investigation may not, at that time, be considered
to be of sufficient significance to warrant a recommendation.
However, the Bureau considers that any indication of a safety
deficiency present in the aviation system, cannot be ignored and
must be notified to the relevant agency. Therefore, a Safety
Advisory Notice is issued in order to evoke thoughtful discussion
and, where appropriate, action on the part of the action agency.
Under the terms of the Memorandum of Understanding between the
Bureau and Airservices Australia, the Bureau does not require a
formal response; however, any feedback is appreciated. It can be
noted that there have been a number of instances where safety
action of both a minor and sometimes significant nature, has
resulted in response to Safety Advisory Notices.
Your response indicates that Airservices Australia acknowledges
that there are issues of concern in relation to 'Team Operations',
namely the assessment process for Air Traffic Controllers, and
human factors training. It is also noted that Airservices Australia
is currently taking action to address these issues and may be
reviewing aspects of operational supervision. It would therefore be
appreciated if the Bureau could be kept informed on the progress of
the initiatives being implemented.