34th ATS/Airline Safety Forum Health Check Simon McDonald Safety Assurance
The Health Check May 2016 April 2017 Includes scheduled, non-scheduled and military operations Review of Airservices and pilot attributed occurrences
ATS Attributed Occurrences 286 Total 402 Occurrences 8 66 32 Other Other occurrence types accounted for 10 occurrences Failure to Pass Traffic Information Error Loss of Separation Loss of Separation Assurance
Loss of Separation ATS Attributed Trend Average 5.5 per month Standard Deviation 1.5 per month Spike in December 2016 = 10 Sydney 14 Melbourne 14 Location Common Issues Insufficient conflict assessment Monitoring issue CANSO 2015 data shown International Benchmarking
Loss of Separation ATS Attributed Most common errors Most common threats Incorrect clearance issued 5 11 Airspace threats Wrong standard applied 8 6 Aerodrome threats Monitoring issue 13 5 Work load Insufficient conflict assessment 20 4 Sequencing
Loss of Separation CANSO Rate of IFR-IFR LOSs per 100,000 Aircraft Movements ANSP (De identified)
Risk Analysis Tool Severity Repeatability Risk
Risk Analysis Tool Separation Rate of Closure Conflict Detection Resolution Planning Resolution Execution Recovery Risk of Collision Controllability ATC Safety Nets Pilot Safety Nets Accident Controller Pilot Severity Control Providence Risk
Risk Analysis Tool Systemic Issues Non-Systematic Human Involvement Issues Window of opportunity Repeatability Risk
Risk Analysis Tool Risk ATS System RAT Scores LOS and LOSA Severity A B C E Total 1 3 Repeatability 2 1 1 2 4 Risk to be mitigated 16 3 4 5 26 35 Risk to be monitored 7 4 8 14 34 56 No further action 77 5 1 1 2 Total 17 21 62
Risk Analysis Tool Risk ATS System and Airborne RAT Scores LOS and LOSA Severity A B C E Total 1 3 Risk to be mitigated Risk to be monitored No further action 17 2 2 2 4 Repeatability 7 3 4 6 26 36 76 4 8 15 32 55 5 1 1 2 Total 18 22 60
Loss of Separation Pilot Attributed Issue involved Airspace Infringement Level Bust 5 11 Airspace Level Bust Infringement Climb =4 Descent = 4 Cruise = 1 Cruise =2 Descent = 5 Route Adherence 7 Other 3 Route Adherence Climb = 1 Cruise = 5 Decent = 1 Other Climb = 2 Descent = 1
Breakdown of Coordination
ATS Foreign Breakdown of Coordination
Runway Incursions ICAO Severity ICAO A A very serious occurrence in which a collision was narrowly avoided ICAO B A major occurrence in which separation decreases. Significant potential for collision ICAO C A minor occurrence. Ample time or distance to avoid a collision ICAO D Occurrence meets definition of Runway Incursion ICAO E Insufficient information for assessment
Runway Incursions ICAO Severity ICAO D ICAO A None Recorded ICAO C ICAO B ICAO B Recorded in June & August 2016 ICAO C Increase from previous years 2 13 10
Operational Deviation 87 On Ground Most Common Issues Following the incorrect route Vacated incorrectly Failing to hold short 1 Circle loop one Most Common Locations Sydney Melbourne Perth
Operational Deviation Most Common Issues Height Requirement Climb to incorrect level e 147 2 Climb Circle loop two Most Common Locations Brisbane Sydney Melbourne
Operational Deviation 473 Most Common Issues Route Adherence Level Bust 3 Cruise Circle loop three Most Common Locations East Coast West/Indian Ocean North/Timor Sea
Operational Deviation Most Common Issues Height Requirement STAR Tracking 180 3 Descent Most Common Locations Sydney Melbourne Cairns r text here
ATS Message/Flight Planning Errors Total of 409 occurrences Planned Through PRD Total of 59 18 at Darwin 16 at Sydney Most common error Total of 64 Majority involve Military restricted airspace Incorrect Inbound Route ADSB Status Capability Total of 45 February 2017 Stands out Total of 39 Improvement from last forum Incorrect Route (Enroute)
Threat and Error Management Incomplete/ Incorrect info during coordination 7% Information Error Data entry error Incorrect clearance issued 5% 8%
Threat and Error Management Altitude Deviation 14% Airspace Infringement Airspace Design PRD and Airspace reservations 12% 10% Winds Go Around Windshear Insufficient conflict assessment 3% 14% 11%
Safety Report Graphical summary Occurrence Reports Includes ATS and Company attribution
34th ATS/Airline Safety Forum Health Check