Although Airservices Australia used applied operational risk assessments to high-level threats, it did not formally assess and manage the risk of specific threat scenarios. As a likely result, Airservices did not formally identify and risk manage the threat of separate aircraft concurrently carrying out the MARUB SIX standard instrument departure and a missed approach from runway 34R at Sydney Airport, even though it had been a known issue among controllers generally.
The ATSB considers that, ideally, specific threat scenarios would be individually recorded, analysed, and tracked on an ongoing basis. However, the inclusion of specific scenarios in periodic risk review activities improves risk record-keeping, and more frequent operational risk reviews now conducted by Airservices Australia are likely to significantly enhance the ongoing identification, assessment and treatment of specific threat scenarios.
Airservices advised on 14 June 2023 that 2 ‘escalation factors’ (elements of a risk assessment) were added to the operational risk assessment (ORA) in November 2020. The escalation factors added were:
These were removed on 2 Dec 2021 with implementation of the runway 34R missed approach redesign (which now had a turn point that closely replicates where an aircraft on the MARUB SIX SID would commence turning).
Following further correspondence with the ATSB, on 1 September 2023 Airservices advised:
Since 2019, we have continued to evolve our operational safety risk management processes. Recent enhancements, supported by integration into the Corporate Integrated Risk and Reporting System (CIRRIS), including:
