Loss of separation (LOS) incidents attributable to pilot actions in civil airspace are not monitored as a measure of airspace safety nor actively investigated for insight into possible improvements to air traffic service provision. As about half of all LOS incidents are from pilot actions, not all available information is being fully used to assure the safety of civilian airspace.
The Australian Transport Safety Bureau recommends that the Civil Aviation Safety Authority, in consultation with Airservices Australia and major aircraft operators, use all available information to assure the safety of civilian airspace through actively monitoring and investigating loss of separation incidents attributable to pilot actions in addition to the current focus on air traffic services-attributable occurrences.
The ATSB acknowledges that as Australia’s independent transport safety investigation agency, it has a role to investigate serious incidents, including serious LOS incidents resulting from pilot actions. Such investigations provide an opportunity to learn from others’ errors and correct any system issue identified, both in the ATS environment and in the aircraft operation environment.
Therefore, the ATSB is committed to undertaking investigations into all LOS occurrences classified as serious incidents, including those that appear to be a result only of pilot actions.
I accept this recommendation and CASA will address the issue. CASA currently monitors and reviews safety occurrence data, including reported Loss of Separation (LOS) incidents, to determine whether a potential safety issue exists or there has been a regulatory breach.
This process is described in the CASA Surveillance Manual. Occurrences are assessed to determine their criticality, and appropriate follow-up investigative actions are determined with regard to a number of factors. Some information can be, and often is, obtained through consultation with Airservices Australia and from internal investigations conducted by aircraft operators. CASA will ensure that every reported LOS incident is assessed, and where considered to be potentially attributable to pilot actions, will conduct further investigations in relation to potential safety issues or regulatory breaches and record the outcomes.
I acknowledge that there will be a meeting on 14 January 2014 between the ATSB, CASA and Airservices to further explore this safety recommendation. Depending on the outcome of this meeting this response may be updated to reflect any agreed action as appropriate.
The ATSB welcomes CASA’s commitment to address all aspects of the identified safety issue through the monitoring of pilot-attributable loss of separation incidents and investigation outcomes of these incidents.
Since this response, the ATSB has met with CASA and Airservices Australia to discuss practical solutions to address the safety issue. It was agreed that it would take a combined effort between airlines, Airservices Australia, and CASA. To help clarify the safety issue, the owner of the safety issue has been changed from Airservices to CASA. The safety recommendation has also been recast to improve the clarity of the expected actions to assist CASA in achieving a practical and on-going solution to:
The Australian Transport Safety Bureau recommends that the Civil Aviation Safety Authority, in consultation with Airservices Australia and major passenger aircraft operators, should ensure the use all available information to assure the safety of civilian airspace through actively monitoring and the gathering of information concerning contributing factors for loss of separation incidents attributable to pilot actions in addition to the current focus on air traffic services-attributable occurrences.
