Air traffic controller endangered two flights: incident report

Updated with full ‘contributing safety factors’

An overworked and under-trained air traffic controller twice endangered a Qantas 737-800 and a Virgin Australia 737-800 near Brisbane on 29 July 2011 according to a report into the incidents published by the ATSB this morning.

The AirServices Australia controller directed the Virgin jet to descend through the altitude assigned to the Qantas jet twice in quick succession by not understanding what was going on, and being corrected by the crew of the Qantas jet.

Despite corrective action by the controller, the separation between the two jets, with a combined capacity of  approximately 348 seats was reduced to as little as 400 feet vertically and 7200 metres laterally compared to a minimum safe standard of  no less than 1000 feet  and 9300 metres respectively.

The summary of the ATSB report and a downloadable version of the full report, with scary diagrams, can be found here.

However nothing is as scary as what the ATSB says it found, and what AirServices Australia said is was doing.

What the ATSB found

The Australian Transport Safety Bureau (ATSB) identified that the controller received a reduced amount of on-the-job training, was allocated multiple training officers, and was required to intermittently staff another control position during and immediately following their training on the Gold Coast en route sector. As a result, the controller probably had not consolidated effective control techniques for the sector, particularly for high workload situations.

The ATSB also found that, even though the quality of the controller’s training had been affected by several factors, the controller’s planned on-the-job training period had been reduced from 6 weeks to 4 weeks. More importantly, there was no requirement for a systematic risk assessment to be conducted and documented when the planned amount of training for a controller was reduced.

What has been done to fix it

Airservices Australia advised that it would develop a training variation form to systematically assess risk associated with amendments to the planned length of controller training programs, and completion of the form required the involvement of the controller’s line manager and the Operational Training Manager. Airservices also indicated several other proposed enhancements to its controller training.

The ATSB has been saying similar things to this for at least three years, as has AirServices Australia, but which has a history of lying to the media when it came to completely losing a Virgin Australia 737 on a flight between Sydney and Brisbane last year.

Unless this cycle of adverse findings and platitudes is broken with a major investment in training, and the culling of incompetent managers, it will all end in mass slaughter and an inquiry as to how and why the clearest of warnings of danger in Australian ATC were either ignored or ineffectively addressed.

This is the full list of contributing safety factors found by the ATSB. Some have been highlighted.

Contributing safety factors

• The unrestricted speed reduction approvals issued to both aircraft did not ensure that the aircraft would enter the holding pattern optimally positioned to assist the controller to achieve the required sequencing.
• The controller did not observe or identify that VH-VOT overtook VH-VZC prior to the aircraft entering the holding pattern.
• The controller twice assigned VH-VOT descent through the flight level of VH‑VZC, and did not detect the resulting loss of separation assurance.
• Due to a complex traffic situation and limited experience on the Gold Coast sector, the controller was experiencing a high workload at the time of the occurrence.
• The controller received a reduced amount of on-the-job training, was allocated many training officers, and was required to intermittently staff another control position during and immediately following their training on the Gold Coast sector. As a result, the controller probably had not consolidated effective control techniques for the sector, particularly for high workload situations.
• The controller had incomplete knowledge of the Australian Advanced Air Traffic System’s Hold Window functionality.
• Resource constraints affected several aspects of the controller’s training and consolidation, and ultimately these constraints were not effectively managed.

There was no requirement for a systematic risk assessment to be conducted and documented when the planned amount of training for a controller was reduced.

This is Australia. It’s 2013. And we have a third world air traffic control system, and a system of oversights and corrective actions that are leaving the flying public exposed to mortal peril.