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ATSB updates information about ‘lost’ Virgin Australia 737

The Aviation Herald graphic of the path of the lost Virgin 737-800

The ATSB update on the incident on 28 September in which AirServices Australia lost its awareness of a Virgin Australian 737 for most of its flight between Sydney and Brisbane is a detailed reminder that the air traffic controller is a danger to the safety of flight in our skies until it fixes some significant deficiencies in the competencies of its controllers and its management.

This was an incident in which the original notification of the incident to the ATSB  was amended to tell the truth to the ATSB after an initial attempt to portray it as a procedural error.

It also lead to AirServices Australia issuing statement that lied about the nature and seriousness of the incident, and continuing to lie about it even when Plane Talking published the amended incident notification (below).

This link ends with a guide to the reporting of the incident and the untruthful description of it provided by AirServices Australia in a chronological sequence.

In its attempt to discredit the Plane Talking report AirServices Australia this is what the Acting Chief Executive Officer of AirServices Australia, Andrew Clark, said, in the second of two untruthful statements made to this publication.

The aircraft was never ‘lost’ to Airservices air traffic controllers. It continued to be displayed on all air traffic control displays managing the airspace and was not in the vicinity of any other aircraft.

The lost status of the flight is however confirmed in this section of this morning’s ATSB update.

The 737’s flight data record had been inhibited on the controllers’ displays for a total of 27 minutes, which was equivalent to a flight distance of about 222 NM (411 km). During this period, none of the controllers involved were aware of the aircraft’s presence in their respective airspace. There was a loss of separation assurance. The ATSB has examined the recorded radar data and found no separation conflicts in the affected airspace during that time.

 

The issues that have arisen from this incident, and many other examples of dangerous and incompetent behavior by the air traffic controller are of acute concern.  Australia has an ATC provider with a proven inability to safely and professionally separate airliners, and a management that lies.

This is totally unacceptable, and puts Australian and foreign airliners in our skies at risk.

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  • 1
    comet
    Posted November 15, 2012 at 5:57 pm | Permalink

    The lying and cover-ups, all reported here, should have been enough for heads to roll immediately.

    That didn’t happen. The minister continues to sit on his hands.

    Albanese, I like you as a person, but you have utterly failed in your job. All the evidence you need has been presented to you on a platter. You should have acted swiftly and decisively, but instead you decided to do nothing about this dire situation.

  • 2
    quick wins
    Posted November 15, 2012 at 10:35 pm | Permalink

    The ‘management’ of information has become the prime function at Airservices Australia. And anyone who reads what is going on in those other organisations, CASA and ATSB would draw a similar conclusion about them. The connection between all three is the Minister. He doesn’t want to hear bad news. Unfortunately there is just too much of it to keep a lid on anymore – the chickens are coming home to roost.

    The destruction of the safety first ethos within Airservices has been slow, but very effective, the proverbial death by a thousand cuts.

    But the Orwellian control of information is breathtaking. It is only when information ‘escapes’ from the fortress that the true might of the bureaucracy is on show – or perhaps not ‘on show’ – for all, within, to see.

    My sources tell me that the article by Ben on this incident, has already seen two controllers permanently suspended by the organisation, with ongoing interrogations as to the source of the information continuing. This is so typical of the intimidation and bullying that some very very scared middle managers engage in, that it apparently barely raises an eyebrow from the few experienced controllers left in the organisation. It also appears to be particularly focussed in the large centre located in Brisbane, run by some interesting personalities. There is a suggestion that even Airservices own in house lawyers are very nervous about some of the antics that have been employed to intimidate individuals within the Brisbane Centre, and are growing weary of continuous invitations to appear before the Fair Work Australia Commission to explain their actions. Just this week, it has apparently escalated to a pending civil suit against one of the senior managers by a suspended controller.

    Re-editing, Managing in-house, altering, omitting, being careful not to document… these are all the required skills now to keep your position as a middle manager in the ‘company’. Whenever a paper trail is raised, heads are bound to roll.

    The pressure that controllers work under is immense, but it is not just through the nature of the work itself – it is mostly from the toxic culture that prevails.

    There seems a determined institutional unwillingness to address the parlous state of resourcing required for the organisation to not only adapt to the rise in air traffic, but to simply sustain itself. Whilst the recently released annual report talks of around 1000 air traffic controllers in the organisation, what it does not clearly state is how many of those are utilised AS air traffic controllers, i.e. Licenced and Operational. That number is as low as less than 700. What this means is that levels of overtime are spectacularly high, burnout is real, fatigue is real, and incidents – the ones you don’t hear about – are rising. It also means that promised panacea projects can not be completed by current operational staff. Indeed, the ongoing routine check and training of licenced, let alone trainee controllers can not be completed. The controllers who do graduate from the training college often end up ‘parked’ in a sector where there is no capacity to train them – often for months, going stale in skills, and getting frustrated in outlook.

    The leave ‘debit’ on the books – leave owed to controllers that can not be acquited – is remarkable.

    From where does this unwillingness arise? One can only surmise it is at the political level. In essence the structure of Airservices is the problem.

    It can not effectively function as quasi-business/government organisation that needs to provide a dividend to a single shareholder – the federal government – whilst run via a Board and CEO structure, with the top 3 levels of the management motivated by at risk KPI linked bonus elements. It is this structure, and the decisions it has borne, that have led to the state it finds itself in now. It is this structure that has created the dysfunctional culture that prevails, and the previous safety based open reporting approach to aviation – that is essential – being shelved.

  • 3
    Oxygen Oxygen Oxygen
    Posted November 17, 2012 at 3:09 pm | Permalink

    Hi Ben,
    From reading your article I infer that your criticism is of the AirServices organisation. In the first and 2nd last paras however, you refer to “the air traffic controller” which seems to personalise it to the individual.

    If my inference of your intent is correct and your concern is with organisational issues, perhaps you could avoid use of “the air traffic controller” which detracts from your message. IMHO OOO

  • 4
    Over the top
    Posted November 18, 2012 at 4:31 pm | Permalink

    Just Culture 

    An organisation that has a Just Culture encourages the open and free reporting of incidents and accidents,  with in most cases nil Jeopardy  to the reporter. 

    In the aviation industry it is  recognised that it would be unusual  for a reported event to be the outcome of a deliberate act.  A Just Culture recognizes this and allows a reporter to freely self report mistakes, Incidents, lapses,  accidents e.t.c without threat of overly punitive action by the company or organisation. This is not to say that the event would not go without proper investigation , remedial action and retraining if it was warranted. 
    Deliberate unsafe acts would be recognized and dealt with outside of this just culture system and are absolutely not tolerated.

    Most companies and organisations today have an excellent Just Culture policy in place. This is not to allow staff to get off lightly  for sub standard performance  but to give them the confidence that if they do make a error they can share the information with the company/organisation  for the benefit of  all without the fear of loosing their job.

    The information contained within a safety report allows the gathering of data, analysis  of trends and refinement of procedures. All this to reduce the chance of the same mistakes being repeated in the future.

    It is a scientific fact that human error is unavoidable.
    In fact the generally agreed average number of mistakes made by the Flight crew of a commercial aircraft on each single flight is around 4.

    These errors are normally small and are usually picked up by adherence to standard operating procedures that have been devised and refined over time to create checks and balances. Those that slip through are then hopefully picked up by other systems such as Traffic collision alerting systems, Ground proximity warning Sytems, configuration warning systems and in a more domestic setting , that annoying chime you get when you open the door of your car and the headlights are still on.  

    If Humans didn’t make errors we would not put so much time effort and money into developing procedures, cross checks and systems to help prevent them.

    James Reason described  errors and defenses by comparing them with layers of Swiss cheese. The Swiss cheese layers are defenses and the holes in the cheese are potential errors or threats.  When the holes in these defensive layers of swiss cheese meet up an error is allowed to pass through unchecked  leading  to an event. 
    (Similar to the way Queensland often passes unchecked to the goal line in the State of origin.)

    The error you describe in your blog was defended by the aircrew saying , in laymen’s terms …..
    ” hey guys we are feeling a bit neglected up here isn’t it about time for a frequency change??
    ( The layer of defense that broke the error chain.)

    When  errors causes a catastrophic event we have Safety departments and the ATSB in place to study these events. From this we learn how they slipped through the layers of defense ( swiss cheese layers) and we devise new systems and procedures to prevent them from happening again ( more layers of swiss cheese) . 

    Some major and high profile accidents and incidents have bought about swift and deliberate change in systems and procedures for improvement of safety.
    Most safety reports however are received as a result of relatively minor reportable errors. Thousands of these  are received each year by safety departments from staff who are happy to self report because of healthy systems of just Culture.  All these reports lead to monitoring of trends and development of improved procedures and systems.

    A healthy Just culture takes years to develop  because  the system needs to gain the trust of the people who use it, however It would take just  one demonstrated breakdown in the system for people to loose trust in it causing a huge reduction in the free reporting of information to safety departments.

    The ATSB provides a very accessible database of safety reports designed to be used by industry professionals. These reports provide factual information designed to help prevent the mistakes of the past from happening again in the future.

    The biggest threat to Just culture in this country is the trolling of these reports by the media to use as sensational front page newspaper reports and Internet Blogs.  
    People are starting to question if the reports they submit will land them in the spotlight via one of the above mentioned medium, effectively bypassing the companies own just culture system. This is not healthy for the encouragement of self reporting or for the industry.

    Ben, you say  we have a problem with  under reporting of incidents.
    Don’t forget that every incident you report started out by somebody involved self reporting it long before you came across it.

    Although I generally enjoy reading your Crikey Blog, when it comes to subjects  such as this I would respectfully ask you to consider the fact that you may be  part of the problem .

  • 5
    Ben Sandilands
    Posted November 18, 2012 at 5:18 pm | Permalink

    Over the Top,

    Your very well expressed comments about Just Culture are very welcome and an important contribution to the discussion.

    However I am puzzled as to being a part of the problem, which implies that you would prefer the media to stay away from the reporting of failings in the public administration of air safety, which in large measure, the media does ignore, since it is rarely the subject of a hand out from the PR machines.

    If you turn to the screen grab of the incident report you will see that it was amended in order to elevate it from being passed off as a procedural error to something much more serious and important.

    As pointed out in the very first post, this action was taken to change the original notification because of the protests of some of those on duty at the time of the incident.

    A determined attempt was made to cover up this incident, and Just Culture has nothing to do with it. This was followed by deliberate lying about the incident by the acting CEO of AirServices Australia.

    If the organisation’s management cannot tell the truth, it cannot be trusted. Nor can there be any confidence that a favourable safety outcome will be pursued.

    In the reporting of these and other loss of separation assurance incidents it has also been reported here that there are issues with the competency of the staff linked in most cases to failings to complete recurrent training or validate standards.

    These are very serious matters, and they have increased in frequency and persisted without any obvious improvement for a matter of years, to the detriment of public safety.

    It is not clear in some of these incidents whether they were in the first instance reported by the airlines or by ATC. What is clear to me is that the airlines are deeply troubled by the nature and frequency of these incidents.

  • 6
    Over the top
    Posted November 28, 2012 at 1:31 pm | Permalink

    Ben, in your blog dated  04 October 2012  you state the original report went as follows……

    “It was reported that the aircraft’s details were inadvertently inhibited in the Air Traffic Management system for approximately 30 minutes.
    There was a loss of separation assurance.
    The investigation is continuing.”

    What more do you want? This describes exactly what happened and is more than enough to get the ball rolling on investigating the incident.

    What worries me is that your reports may have influenced the change in the title and description of the investigation ( for no productive reason) which means that media pressure is influencing how people are going about their work in relation to these events and that has everything to do with just culture.  (Or the Dilution of it)

    I think your job in regard to active investigations is to wait until the report is completed and then if you consider it to be inaccurate , bring it to public attention.(similar to the Medivac report).  I am not saying that the media should keep,out of these reports, but at least wait until the investigation has concluded so as to not influence the outcome.

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