ec a th i lrp ob u s f y edition 02 w oct. '07 Net/Safety-netEdition2.pdf · 2011-08-04 · ec a th...

edition 02 oct. '07 we catch it all we report it all all about safety

02

safetysurveyfeedback

03

positive building blocks

challenges

06

the sms

07

safety tips

competitiontime

10

use of the phrase'maintain'

12

11 safetyscenarios:january tojune2007

issue 02 page 02we catch it all we report it all all about safety

safety survey feedbackThe survey was based upon empirical research and survey methods applied by SafeMap. Safemap is an international survey company that conducted a safety survey of the Australian Minerals Industry 1999, which has been considered one of the most significant surveys in the history of safety surveying due to the sheer size and the statistical success and accuracy of the survey results.

In order to enable ATNS and Standards Assurance to determine the challenges that lie ahead within our corporate approach towards

SAFETY, the survey was used to determine staff's perception on the safety culture of ATNS and the safety reporting culture.

The Safety Survey was conducted over a period of 5 weeks during November/December 2006. The aim was for a response of 75% of all operational staff, i.e. Technical, AIM, ATSA & ATC. The response rate was 62% (280/450) of the total amount of operational staff. Thus signifying the survey as representative of the total operational staff complement.

FAJS

FACT

FADN (FAVG)

FAPE

FABL

FAEL

FALA

FAWB

FAUP

FAPM

45%

48%

67%

100%

73%

79%

100%

80%

100%

100%

FARB

FAGG

FAKN

FAPP

FAGC

FAGM

FAKM

FAMM

FAAB

FAPN

100%

100%

100%

40%

50%

13%

100%

100%

100%

0%

Limitations to the study were The slow response rate from the 2 major stations, i.e. FAJS 45% & FACT 48%; The exclusion of the ATA and non-operational staff;The communication and motivation to staff indicating the value in participating in the survey andThe lack of differentiation between responses from the relevant disciplines, i.e. Technical, AIM, ATSA, ATC.

In order to be able to determine the success of ATNS's response to the survey on improved safety management and implemented initiatives, a follow-on survey is planned for July 2008. Any queries may be forwarded to

••••

[email protected]

Well done to FAPE, FALA, FAUP, FARB, FAGG, FAKN, FAKM, FAMM, FAAB, FAPM andFAJS Technical for achieving a 100% response rate!

The response rate per station was as follows:

issue 02 page 03we catch it all we report it all all about safety

Interested in more???

[email protected].

The final report and graphs of the survey is available on the portal under “Manager's briefcase” and the Safety & Regulation Oversight link. Your input will be appreciated. For those that indicated they are willing to participate in follow-up e-mail or focus group discussions, we apologise for the delay and request you to forward any matters pertaining to the survey and the safety culture to

Unfortunately due to the vast geographical spread of those willing to participate in the safety survey focus groups, these will not be conducted due to logistics.

Four topics have been selected as positive building blocks for future development and in addition, five challenges are highlighted for immediate action:

50%

45%

40%

35%

30%

25%

20%

15%

10%

5%

0%

49%

36%

11%

3%

1%

Strongly agree Agree Unsure Disagree Strongly disagree

Q1: ATNS is seriousabout safety

responses

60%

50%

40%

30%

20%

10%

0%

17%

53%

36%

12%14%

5%1%

responses Q30:

Our tools and equipment are safe & well maintained

60%

50%

40%

30%

20%

10%

0%

54%

36%

5%

4%1%1%

1%

responses

Q31: I enjoy the work I do

4Positive Building Blocks



we catch it all we report it all all about safety

safety survey feedback, cont.

issue 02 page 04

25%

62%

2%1%

11%


70%

60%

50%

40%

30%

20%

10%

0%

Q33: Given the opportunity,I can make improvements in my job

responses

Q8:

40%

30%

25%

20%

15%

10%

5%

Strongly agree Agree Disagree Strongly disagreeUnsure

0%

35%

36%

17%

6%

38%

4%

responses

You can trust the managers at ATNS

responses

Q4: ATNS is interested inemployees' views onsafety

40%

30%

25%

20%

15%

10%

5%

Strongly agree Agree Disagree Strongly disagreeUnsure

0%

45%

35%

28%

13%

4%

44%

11%

5Five Challenges


issue 02 page 05

responses

25%

Q16: My manager followsthrough on safetymatters

60%

50%

40%

30%

20%

10%

0%


19%

2%

19%

51%

9%

responses

70%

60%

50%

40%

30%

20%

10%

Standards'response slow

Manager'sresponse

Ineffectivecorrective

action

Managerial non-response

14% 12% 11%

62%

0%

Negativeconnotation

0%

Too mucheffort

Victimisation None

0% 0% 0%

Q49: What will make youthink twice aboutreporting a minorincident?

responses

40%

30%

25%

20%

15%

10%

5%

Disagree Strongly disagreeUnsure

0%

45%

35%

41%

13%

3%

37%

6%

Strongly agree Agree

Q19: When you break asafety rule, you willbe treated fairly


issue 02 page 06

the smsAs many of you know, the SMS is a requirement from ICAO and requires aviation role players to implement various facets of this system, i.e. safety monitoring, auditing, promotion and assessment. To shed some light on the newly appointed positions of Technical Standard Specialists their responsibilities within this system are explained.

This is a newly born discipline within the Standards Assurance section which deals with the responsibility for the development and maintenance of an effective safety management system for the technical field. This means from now on there will be policies and procedures tailored to accordingly address, where applicable, the inefficiencies and nonconformities of the technical field with regard to CAA and ICAO rules and regulation.

The TSS discipline is situated at ATNS' Head Office under the umbrella of the ATM/cns Department. It started operations on 1st of May 2007 and consists of two experienced technical members - Andrew Walbank and Sifiso Mkhize, under the leadership of Luke Hawkins - Manager Standard Assurance.

To add value to the ATNS technical field by ensuring conformance to the safety standards and regulations are maintained, and that procedures are in place for work being conducted.

Minimise the risk associated with human error by ensuring that proper and clearly defined regulations are in place.

Although Technical Services is seen as a support function within ATNS, they play a pivotal role in the Safety Management System. TSSs will mostly depend on the feedback from the technical field to conduct their work efficiently – the TSSs can be seen as the safety voice for the technical field.

Technical Standard Specialist (TSS)

Commitments:

•

•

•

•

Implementation of SMS in the TSS section

Develop and maintain a high level of safety culture and awareness by promoting safety.

Ensure that all technical personnel are provided with adequate and appropriate safety information and training.

The following TSS responsibilities are relevant to the facets of the SMS:

Incident reporting & investigation

Maintenance Monitoring System

Report to SACAA

Technical personnel licensing

Plan

Conduct actual audits

Follow-up

System description

Estimation of the severity of the consequences of hazards occurring

Evaluation of risk

Development of safety assessment documentation

Communication

Training

Lessons learned

SAFETY POLICY

•••••••

SAFETY AUDITING

•••••

SAFETY MONITORING

•••

•

•••

SAFETY PROMOTION

•••••

Service Level Agreement monitoring

Executive reports

Competency monitoring

Prepare

Audit report

Identification of hazard

Estimate the likelihood of the hazard occurring

Mitigation of risk

Safety campaign

Awareness


safety tips

competition time!!Don't forget to forward us your creative safety ideas! Send it to The most creative safety ideas and initiatives will walk away with fashionable ATNS trolley bags designed by fashion guru Pierre Cardin and imported from Nigeria.

We are looking for anything that is safety related and that will improve safety awareness, safety consciousness or promote initiatives within ATNS. Even safety stories or aviation related jokes focussing on safety awareness vs misunderstanding will be appreciated. These stories may originate from the Technical, AIM, ATSA or ATC environment.

[email protected].

Send entries via e-mail to

It has been decided by the editing team that the safety competition will be an ongoing event and thus winners will be announced and awarded as they are identified for creative newsletter ideas and/or safety concerns/initiatives raised. Keep a look-out for our first winner in the 3rd edition due at the end of January 2008.

[email protected],

issue 02 page 07

10

10

With the compliments of NATS the following tips were distributed in the United Kingdom as part of an industry-wide campaign to improve RT standards. RT discipline is a worldwide problem and encompasses both the ANSP and the flight deck crews.

Communication error is the biggest causal factor in both level busts and runway incursions in the UK. The following tips were recommended for controllers to help improve RT standards:

Use clear and unambiguous phraseology at all times – challenge poor RT;

All frequency changes should be kept separate from other instructions whenever possible;

Monitor all readbacks; try to avoid distraction – especially the telephone;

Always insist on complete and accurate readbacks from pilots;

All executive instructions relating to headings ending in zero should be followed by the word “degrees”;

Communication error is the biggest causal factor in both level busts and runway incursions in the UK. The following tips were recommended for pilots to help improve RT standards:

Maintain RT discipline – use clear and unambiguous phraseology at all times. Avoid unnecessary RT;

Do not read back a clearance as a question, and avoid asking confirmatory questions on the flight deck (i.e. “he did say flight level 110 didn't he?”);

On frequency change, wait and listen before transmitting;

Check RT if there is a prolonged break in activity on the frequency;

ATC instructions should be recorded where possible;

Avoiding communication error: top10 tips for CONTROLLERS

••••••

•• W A Y S R A Y L WAYSRAYL•

•

Avoiding communication error: top10 tips for PILOTS

•

••

•

••

••••

Try to avoid issuing more than two instructions in one transmission;

Use standard phraseology in face-to-face and telephone co-ordination;

Aim to keep RT delivery measured, clear and concise, especially when the frequency is congested. But, if it's urgent, sound urgent;

rite s ou peak, ead s ou isten ( );

If you are unsure, always check!

Both pilots should monitor the frequency whenever possible;

Ensure you pass all information relevant to your phase of flight, i.e. on departure, pass callsign, SID, passing level, cleared level or first step altitude;

Take particular care when issued with a conditional clearance. When reading back a conditional clearance, make sure you state the condition first;

Set the clearance given, not the clearance expected;

If you are unsure, always check!


who is committed

trm continuation training

a safety message fromEM: SD - Boni Dibate

ATNS is proud to operate and maintain the largest and safest air traffic system in Africa. Our employees safely orchestrate the take-off, landing and routing of close to 1600 aircraft a day across SA continental and oceanic controlled airspace, enabling economic growth and providing a better quality of life for South African people.

Since the introduction of low-cost carriers to the South African aviation landscape, ticket prices have declined dramatically and opened up air travel to all the citizens of South Africa. ATNS is proud of the role we play in the growth of this market; we have continually stayed ahead of demand by at least three years in delivering ATM capacity.

To support this growth, we must always return to our first priority – safety. We will continue to do everything we can to uphold that commitment to the flying public. Reducing operational errors and runway incursions as airline traffic grows is a shared responsibility among pilots, air traffic controllers and vehicle drivers. I believe our enhanced safety awareness, through project SURGE, as launched in September 2005, will enhance our awareness and the improved procedures should contribute to our overall safety.

Moving South Africa safely, it's what we do!

We are personally committed and our interactions are thus dominated by our obligations associated with this commitment. These obligations may be mutual, or self-imposed, or be explicitly stated or not, but ultimately our interest is in safety.

A first for ATNS at FAEL? Yes, some of you may have heard about the TRM Continuation training that was under development, well that was completed in January 2007 and followed by two pilot training sessions at FAWB and FALA. Fortunately the FAEL ATSU took it a step further under the initiative of Tyrone Spykerman and invited the Manager: Training Integrity and the Human Factor Specialist to FAEL for a team analyses combined with a team build and an extended TRM Continuation training course.

It started off with a personality analysis of the whole FAEL team on an individual as well as a team level and this developed into a group

discussion where staff were allowed to evaluate and discuss a diagnoses of themselves and their team. This was combined with physical team build activities where the team could experience their strengths and weaknesses first hand. The Manager: Training Integrity, Ian Joubert facilitated a group session where the team had to decide what has to be developed to build on their strengths and counter their weaknesses.

Day two was used to set up the connections between the personality traits discovered on Day one and the operational field. This included another team build activity, presentations and individual exercises that focussed on ATNS's

issue 02 page 08


number one strategic imperative – SAFETY. In basic terms Safety is a Team Effort and staff were introduced to the two main causal factors of safety occurances during the past 8 months, i.e. situational awareness and procedural non-adherence. The exercises highlighted the importance of looking after each other in the team and identifying processes/procedures not conducive to safety at FAEL, thus empowering staff to take responsibility for change.

All in all it was a great learning curve for the staff of FAEL as well as the facilitators and we urge you to identify your possible challenges within your team and working environment. If you are interested in a similar facilitation at your station or require more info, please forward your request to:

Finally, a great big thanks must go to Johan Minnaar, Andrew Douglas, Tyrone Spykerman and the FAEL team for a great team effort. Well done!

[email protected].

Can you identify the location and name of this airport?

[email protected] your answers to

and stand a chance to win a cool corporate gift.

: A South African airport with an elevation of 1933’ and a RWY length of 2501m.

CLUE

trm continuation training, cont...

who is the atns reigning brain?

issue 02 page 09

Photo supplied with the compliments of Rob Krummeck


With compliments of NATS we also publish a Safety Notice they circulated in May 2007. A recent ATC incident occurred whereby the crew of a flight interpreted the phrase “Maintain FLXXX” as an instruction to descend, causing an Airprox.

An ATC error led to the wrong flight level being stated in the phrase. This was then mistakenly interpreted by the pilot, who believed he was getting a descent clearance.

In this particular incident Aircraft A and Aircraft B were in close proximity and both routing via the same reporting point. Aircraft A was at FL8O, under the control of an Approach Controller and Aircraft B was at FL7O under the control of a Sector Controller. Aircraft A called on frequency. The Approach Controller instructed Aircraft A to “Maintain FL7O”, which Aircraft A read back correctly and initiated a descent. Aircraft A then called the Approach Controller and asked if there was traffic at FL7O to which the Approach Controller responded “Affirm maintain FL8O as you were instructed. Climb FL8O”. At the same time Short Term Conflict Alert activated. Aircraft A reported a TCAS climb RA.

If an aircraft reports climbing or descending to a level on first contact, do not use the phrase “Maintain FLXXX”. Use caution when using the word “Maintain” with a level. FAA trained aircrews can interpret “Maintain” as a climb/descent clearance and in this recent incident, the aircraft involved was a UK airline with a non UK pilot. The technique of reading the levels on the strips whilst listening to the readback has been shown elsewhere to help detect this type of human error.

In the UK the phrase “Maintain” is used for level flight and is not used instead of ‘Descend” or “Climb”. If the phrase “Maintain FLXXX” is used for anything other than your current level, check it with the controller.

Editor’s note: This is also the case for South African airspace, where the phrase “Maintain” is used for level flight and is not applied as a synonym to instruction for “Climb” or “Descend”.

1. The Incident

Key Message - Controllers

•

••

•

Key Message - Pilots

•

use of the phrase “maintain”

issue 02 page 10


issue 02 page 11

FAJS had an impressive display of weather this past winter and the technicians made sure theymade full use of the opportunity to mix work and play.

Anybody struggling with GLARE in a Tower? We would like to hearfrom you and your possible solution may just land you a reward!

winter wonderland

visibility?

safety events: january to june 2007- scenario 1


The controller was providing an area control service on the FACT Area West sector. A B738 was routing from FAJS to FACT maintaining FL280 indicating a ground speed of 420kts, while a BE20 was also maintaining FL280 and indicating a ground speed of 230kts, routing from FAPY to FACT and at that stage 80NM ahead of the B738. Training was in progress on the FACT Approach sector and as a result the area controller was requested not to sequence any inbound traffic. At the time there were ten aircraft on the Area West frequency with an additional five approaching the sector boundary inbound from the FACT East sector. At time 1321UTC Approach contacted Area West with a request to commence the sequencing of traffic and at that stage the B738 was 50NM behind the BE20. The controller afforded all attention to sequencing the aircraft from the east and at time 1333UTC, the B738 offered to descend or climb and slow down in order to assist the controller in sequencing (20NM behind the BE20). The controller declined the offer of assistance and at time 1334UTC the STCA activated at 15NM. In response, the controller turned the B738 right onto a HDG of 330° (90° off track) and requested the BE20 five times to descend to FL270. On the fifth transmission the pilot of the BE20 responded and separation reduced to 9.8NM.

The investigation determined that no essential traffic information was passed and an excessive turn 90° off track was issued to the B738. The Loss of Separation (LoS) was primarily caused by the controller's fixation on the sequencing of five aircraft inbound from the Area East sector, though numerous contributing factors did however add to the fixation. FACT management is commended for their controller support/relieve after the LoS, as this was exemplary of a safe system that ensures no secondary controller failures occur as a result of the first error.

The controller was counselled on basic ATS Surveillance procedures and passing of traffic information. It was recommended that Service Delivery (SD) Management ensure that FACT continuation training includes sessions on the recurrence training for staff in the provision of essential traffic information. The SACAA was requested to provide feedback on actions taken to encourage vigilance from pilots operating within controlled airspace. A letter was sent to the operator and PIC of the BE20 highlighting the requirement for a continuous radio watch within controlled airspace.

9.8 NM

B738 maintaining FL 280, instructed to turn right HDG 330 - 90° off track

WY

BE20 maintaining FL 280, instructed to descend to FL 270 on five occasions

issue 02 page 12


scenario 2

At time 1102.42UTC the GMC controller requested a crossing clearance from the Aerodrome controller via the VCCS for a B738 to cross RWY03L at the “E” intersection. At time 1102.35UTC the GMC controller requested to cross a tug as well at the “E” intersection (without using the VCCS). The Aerodrome controller requested RWY03L back at time 1103.02UTC (without using the VCCS) by saying “03 Left Vacated?”. According to the composite audio recording, no clear indication was received from the GMC controller stating that the RWY was vacated. The GMC Controller was busy listening to another read back at the time and responded with an incoherent “uh”. At 1103.19UTC a take-off clearance was issued to a JS41 to depart RWY03L. The take-off clearance was not immediately acknowledged by the crew and when the ATC challenged the crew after a few seconds, they responded with reading back the take-off clearance. At 1109UTC the PIC of the JS41 reported a possible RWY incursion on RWY03L to the Johannesburg Area North East controller. The message was passed to the Aerodrome controller who annotated the remark in the Tower Occurrence Log.

The investigation determined that due to the fact that the GMC Controller did not give a clear indication that the runway was in fact vacated and also that the liaison was not done on the intercom as per the SSI Manual, the Tower ATC should not have cleared the next departure for take-off as he did not yet have jurisdiction of the runway.

The controllers were subjected to corrective training w.r.t RWY crossing procedures, including the R/T to be used when crossing an aircraft and the application of correct procedures. The controllers were also subjected to a disciplinary hearing for the violation of six operational and administrative procedures. It was recommended that Service Delivery (SD) Management ensure that the controllers were made aware that the disciplinary action was due to violations committed and not for any errors. Traffic counts are to be reviewed to ensure reflection of total movements that affect RWY through-put as well as additional movements that count towards overall controller workload (i.e. over flights, vehicular movements and repositioning).

ControlTower

A2

B1

B2

L3 K

03L

E

“C” APRON

A1 I3

JS41 cleared for take-off RWY 03Lwith tug not fully vacated.

A319 cleared to cross RWY 03L on TWY E. Tug 1 cleared to cross RWY 03L in turn.

issue 02 page 13

scenario 3


A DH8C was inbound to FAKM from FAJS maintaining FL180 and routing direct KYV. A C56X was airborne at FAKM and routing to FAJS via WMV, requesting climb to FL330. The DH8C requested descent and was instructed to descend to FL160. On first contact with the C56X, the aircraft was put under radar control and instructed to fly a HDG of 100° (right of FLPN track) and climbing to FL150. Thereafter the C56X was instructed that once established on the HDG, to continue climb to FL210. The STCA alerted the controller at 14.4NM separation and the aircraft passed the same level when the separation was 8.4 NM and this reduced to 7.4NM when the C56X was 800' above the DH8C's Mode C indication. The radar recording indicated that the controller identified the potential conflict well before the LoS occurred, by means of the “Time of Passing” (TOP) tool (Note that the TOP tool does not take drift into consideration). The initial measured distance indicated that the aircraft would pass each other by a distance of 9.3NM and this should have indicated to the controller that additional intervention was required. At the time of the LoS no additional conflict resolution was applied by the controller; and no essential traffic information was provided to any of the two aircraft.

The investigation determined that the LoS was primarily caused by the perceptual error due to the misjudgement of the passing distance between the DH8C and the C56X as well as the controller's failure to maintain diligence and respond to data

obtained from the ASD. The controller had to complete the break shift after the LoS. The hand-over procedure did not include meteorological conditions such as drift and neither did the controller involved in the Los, make use of the grib wind tool when the C56X was turned on a heading for continuous climb. The controller's effort to retain both aircraft within controlled airspace/AWY, can not supersede the requirement to maintain separation.

The controller was subjected to remedial training and a counselling session. It was recommended that SD i) investigate the feasibility of supervisory shifts to allow immediate support/withdrawal from the operational position following an ATS related safety event; ii) Review FAJS Area North/South SSIs pertaining to the use of “Clearances annotated in the TXT field on the FDR label”; iii) Study the use of the TXT field for co-ordination practises using TXT filed/Electronic Data Block. The case study should include the use of electronic co-ordination vs controller situational awareness; iv) Ensure specific guidelines for inter and intra ATSU co-ordination as suggested by ICAO Doc 4444 (Chapter 10); v) Re-enforce the use of standard RT and adhering to SOPs. Redundant procedures should be investigated and updated and procedures to be re-enforced by means of attaining buy-in from staff. A controller's failure to adhere to even redundant procedure will escalate ATNS's liability in the event that a LoS or accident is argued in court.

0

9

18

27

0

9

18

27

0

9

18

27

APDUR

8.3NM

C560 instructed to fly HDG 100and climb FL210

KYV

WMV

BLV

FPL TRACK C560

FPL

TRAC

K DH8C

DH8C maintaining FL 160

issue 02 page 14


scenario 4

A MD82 was inbound from FADN on the Standerton 4A STAR and was radar vectored onto a heading of 360º at FL090 to intercept the LLZ RWY 03L at 15NM. An A319 was inbound from FLLS under the jurisdiction of the Approach West Sector at FL090 and just prior to the handover to Approach East, the A319 reported the field in sight. The STAR was cancelled and the aircraft was placed on a radar heading of 180º; the electronic data block was annotated with “FIS” and “180” to indicate the radar heading; however there had been no verbal coordination. The STCA was activated for approximately eight seconds and then went off as the aircraft entered the STCA inhibited zone. The student on identifying the conflict between the two aircraft instructed the A319 to fly a heading of 190º and to descend to 8000' to ensure separation was not compromised. At the time of the LoS, the aircraft were already diverging and separation reduced to 4.2NM and 400'.

The investigation determined that the LoS was primarily caused by the perceptual error due to the misjudgement of the distance and altitude of the A319 in relation to the MD82. The failure of the Approach West controller to coordinate the A319 w.r.t. the non-standard arrival (modified down wind position) contributed to the error.

The Radar West and East Controller as well as the student were counselled on the importance of standard joining procedures and coordination. In addition, the OJTI was subjected to an OJTI proficiency assessment before resuming duties as an OJTI. It was recommended that SD Management ensure that information pertaining to upper air winds is available to controllers at all times especially prior to commencement of shift and that Grib Winds data reliability are addressed. SD Management to review the coordination for all ATSUs using the EuroCat X system wrt the Electronic Data Block use and its impact on situational awareness.

ControlTower

03R

03L

21L

21R

H

H

FAJS CTR

FALA TM

A

FALA CTR

FAJS CTR

A319 on modifieddownwind HDG 180,maintaining FL 090

MD82 vectored for 15NM intercept of localizer RWY 03L, maintaining FL 090

AVAGO 2A STAR

STA

NDERTO

N 3A

STA

R

issue 02 page 15

scenario 5


A B744 taxiing out for departure and an IL76 under tow were both on the GMC Frequency as the GMC and Tower services were combined for the night shift and single runway operations was in force due to construction on RWY21L. The IL76 had requested to tow from the western side of runway 21R to the old runway 09 and was holding on taxiway H to cross runway 21R. The B744 was given instruction to line up and wait on RWY 21R for departure. The IL76 was then given permission to cross runway 21R and moments later the B744 was given clearance for take-off RWY21R. The pilot of the B744 noticed the other aircraft crossing over the runway and rejected the take-off and vacated runway 21R onto TWY F1.

The investigation determined that the controller was unaware of the event until he was notified by the B744 that the take-off was rejected due to crossing traffic and the controller reported that he had omitted to place the “runway crossing” card on the active runway bay as a memory cue. In addition, the controller failed to activate the Rescue and Fire Fighting (RFF) Services for the aborted take-off. The controller was momentarily distracted when solving the confusion that resulted from prior incorrect towing instructions.

It was recommended that Service Delivery Management: i) Develop procedures for the use of FPS on GMC and Tower that will introduce redundancies into the SMGCS for the crossing of traffic over active runways; ii) Revise the design of

the tower FPS boards to provide additional space in order to elevate physical restrictions and introduce more flexibility to the FPS board management on GMC and Tower; iii) Develop and implement procedures for the use of stop bar lights; iv) Prioritise the planned installation of an A-SMGCS at FAJS; v) Review the methods of traffic counting with the objective of establishing procedures that will accurately reflect the traffic demand; vi) Revise the Flow Management Procedures for outbound traffic routing northbound in order to allow for the proper and easy application of DST during periods of high demand on these routes (such as at night); vii) Install observation equipment, such as Close Circuit Television (CCTV) to monitor the portions of taxiway A and runway 21R/03L that is not clearly visible from the FAJS control tower. It was recommended that the operational training system be amended on the following matters: i) Appointment of a training co-ordinator; ii) Students to be rostered with a specific instructor for longer periods of time to improve continuity; iii) Procedure is introduced for specific remedial training (classroom, simulator or other). The SA CAA have been requested to review the regulations pertaining to the use of lights by aircraft moving on the manoeuvring area at night with the objective to introduce regulation that will enhance the visibility of such aircraft and to align the regulation closer to the ICAO recommended practices including ICAO Manual for the prevention of Runway Incursions, Document 9870.

ControlTower

L3

E

03R

03L

21L

21R

E

E

B744 cleared for take-off whileIL76 is still crossing RWY 21R,vacating TWY F and then advisingATC.

IL76 under tow from D-parkingto old RWY 09

issue 02 page 16


scenario 6

A DH8C and a DH8D-Q400 were both routing inbound on the ESTED 2B arrival for RWY21 and were thus on parallel tracks. The Q400 was passing FL172 when descent to FL160 was issued by the controller. At that time the DH8C was passing FL156 with an instruction to descent to FL120. The Q400 maintained a Rate of Descent (ROD) of approximately 1200ft/min and the DH8C maintained a ROD of approximately 500ft/min. The pilot of the DH8C stated in an interview that he was descending at a low ROD due to the aircraft being below profile as a result of the aircraft's descent being instructed by Area prior to the planned top of descent point. This was done by Area in order to facilitate the descent of two other aircraft, one of which was the Q400. Separation reduced to 4.6NM and 800ft.

The investigation determined that the controller did not pass traffic information to the aircraft. A distraction prior to the incident was caused by two conflicting AVAGO and ESTED STARs arrivals.

The controller applied the Changing Levels and Level Assignment using Mode-C in accordance with the ATS SPM and neither aircraft descended at an extraordinary ROD. The controller was also discussing the handover situation with the oncoming controller at the time of the LoS. Several additional distractions (housekeeping, air conditioning, recent withdrawal from operational duty of a colleague and the death of another colleague's child) to the controller were present during the shift.

The controller was subjected to a proficiency assessment and an additional human factors interview before returning to operational duties. It was recommended that Service Delivery (SD) Management investigate the design of the AVAGO and ESTED STARs as well as the interim procedure to address the STAR confliction. SD Managers were reminded of the dangers of secondary trauma and the importance of assistance/availability of the Employee Assistance Program information to all staff in the event of emotional distress.

ControlTower

03R

03L

21L

21R

H

H

FA

JS

CT

R

FA

JS

TM

A

FALA TM

A

FALA CTR

ESTEDLIV R-240/50

FAJS CTR

ES

TE

D 2

B S

TA

R

Q400 instructed to descend FL 160as DH8C vacated FL 160. STCA activatedas the Q400 passed FL 167 while DH8Cwas passing FL 156.

DH8C instructed to descend from FL 160 to FL 120

issue 02 page 17


The controller was working the Radar South and West positions combined while RWY 03 was in use and CAVOK conditions prevailed. The two aircraft were routing inbound on the ESTED arrival for runway 03R. A B734 was behind and above a DH8C and the controller vectored the B734 to the east of the ESTED STAR's track. The controller had co-ordinated with ACC for the B734 to maintain a high speed (300+ Kts) in order to let the aircraft overtake the DH8C before the aircraft arrived on final approach. The B734 was turned towards the Localizer for Runway 03 before vertical separation existed between the aircraft and this turn resulted in the aircraft flying on near parallel tracks approximately 7.5 NM apart when the DH8C, still complying with the ESTED STAR, turned towards the B734. Resolution action was issued before the loss of separation occurred and essential traffic information was passed to both aircraft as separation reduced to 4.1NM at the same flight level.

The investigation determined that the manoeuvre performed by the controller with the B734 to overtake the DH8C is a normal ATC procedure; however the controller had not established vertical separation before the aircraft were turned onto near parallel tracks. The ESTED2A STAR is not optimally designed from an operational and Human Factor perspective as it differs from other STARS in that it is the only closed STAR at FAJS and it conflicts with other STARs.

The controller was subjected to remedial training and a proficiency assessment before returning to operational duties. In addition, the controller was commended for a text book conflict resolution. It was recommended that Service Delivery management investigate the feasibility of the ESTED STAR and investigate the need for the appointment of supervisors as a safety contingency.

scenario 7

ControlTower

03R

03L

21L

21R

H

H

FAJS CTR

FA

JS

TM

A

FALA TM

A

FALA CTR

ESTEDLIV R-240/50

FAJS CTR

ESTED 2

A S

TAR

B734 on HDG 065 descending to FL 170then turned on HDG 080 descendingFL 110. On passing FL 130 the B734 wasturned onto HDG 060.

DH8C on ESTED STAR maintaining FL160commenced turn as per STAR towards theB734, but not anticipated by controller.

issue 02 page 18


scenario 8

A C404 was vectored from the left base onto the stILS for RWY03R followed by an A343 (This 1 LoS

not depicted on graphic illustration). The C404 was vectored too close in front of the A343 and the speeds of the aircraft were not synchronised for the approach. This resulted in a loss of separation (LoS) of 3.5 NM by the time the C404 passed the outer marker.

Six minutes later a second LoS occurred between a JS41 - turning onto the ILS for RWY03R from the right base leg, and a B744 - turning onto the ILS for RWY 03L, from the left base leg. The LoS occurred while both aircraft were turning from base leg onto the respective localisers. The student's plan for the sequence was to vector the B744 ahead of a JS41 and descended the B744 to 8000ft while keeping the JS41 at FL090. Due to another JS41 approaching straight-in from the south (for runway 03L) the available space to put both the B744 and

st ndthe 1 JS41 on the ILS ahead of the 2 JS41 was diminishing and the student responded by

stswitching the sequence and vectoring the 1 JS41 ahead of the B744 instead. When the aircraft were 5.3NM apart, the student became aware of the imminent LoS and instructed the B744 to expedite his descent. The OJTI was monitoring the situation and queried the student on the situation about the same time separation was lost. Separation reduced to 600ft and 2.5 NM.

The investigation determined that the student's application of speed control was below standard during the training session under review. This contributed to the LoS between the A343 & the C404 and the LoS between the B744 & the JS41. The decision of the OJTI pool to set the training objectives for the student (250 training hours) to

become independent in decision making from the OJTI was in line with the training objectives and resulted in the OJTI not intervening early enough to prevent the LoS. The OJTI allowed separation to be lost in order to pursue training objectives, however this was in contravention of the OJTI procedures as set out in the Manual for OJTI; Chapter 6.5 & 11. The STCA inhibit area denied the controllers alerts in areas where conflict is the most likely to occur, namely the base legs to both runways.

The student was subjected to corrective training on conflict resolution and speed control by means of practical exercises in the SSS. The OJTI and the Approach Planner received written reprimands for not reporting the LoS between the A343 & the C404. It was recommended that Service Delivery Management (SD) conduct a Safety Assessment to evaluate the parameters of the STCA inhibit area. The fol lowing amendments were recommended for the operational training process: i) A mentor be appointed for every student that is responsible for the overall guidance and monitoring of the training process to ensure oversights does not occur and to assist the student in ident i fy ing and rect i fy ing areas of underperformance; ii) The simulator should be used to support the live traffic training and to address specific shortcomings in the students performance; iii) The remedy of increasing pressure to force an increase in performance should not be applied without corrective action first being applied in the simulator and not on live traffic. Finally it was recommended for SD to develop and appoint an additional level of management into a supervisory level at complex units such as FAJS in support of safety.

ControlTower

03R

03L

21L

21R

H

H

FAJS CTR

FALA TM

A

FALA CTR

FAJS CTR

B744 instructed to decent to 8000’ then instructed to turn left ontoHDG 060 to intercept localizerRWY 03L.

JS41 turned to intercept localizerRWY 03R ahead of B744 on RWY 03L with separation decreasing and then taken out of sequence.

AVAGO 2A STAR

STA

NDERTO

N 3A

STA

R

issue 02 page 19


The controller was working the Radar South and West positions combined with thirteen aircraft on frequency, when the CARJ was inbound on the ESTED2A arrival and a B738 was inbound on the IMSOK1A arrival. On the right base of RWY03R the B738 was 7NM ahead of the CARJ. The B738 was instructed to turn right on a heading of 270° and to descend to FL100, while the CARJ had also been descended to FL100. The CARJ commenced the inbound turn as per arrival to intercept the localiser RWY03R, followed by the activation of the STCA. As the B738 was descending through FL109, the aircraft was instructed to turn right on a heading of 360° and cleared for the ILS approach, while at the same time the CARJ was descending through FL104. Conflict resolution was affected and essential traffic information was passed as separation reduced to 4.1NM at the same flight level.

The investigation determined that the radar controller failed to ensure that vertical separation was in place when the B738 was instructed to descend, failed to take cognisance of the published left turn of the CARJ and eleven aircraft were positioned to the east of the aerodrome that required climb-through co-ordination.

The controller was subjected to a dual shift and a proficiency assessment before returning to operational duties. It was recommended that SD management publish by the means of a Directive the declared capacity for FAJS as well as for the TMA including what the acceptable levels of traffic handled by a single controller should be to ensure safety. In addition, SD to develop flow management procedures to regulate the traffic flow and manage the traffic demand according to operational frequencies in operation at any given time. The incident was also exemplary of the requirement of a final director sector at FAJS Approach.

scenario 9

ControlTower

03R

03L

21L

21R

H

H

FAJS CTR

FALA TM

A

FALA CTR

FAJS CTR

B738 on right base 7 NM ahead of CARJ,instructed to turn right HDG 270 and descending FL 100.

CARJ on ESTED STAR instructedto descend to FL 100, on STCA instructed to turn left HDG 270before being vectored for localizerinterception

B742 on final approach RWY 03R no.1

issue 02 page 20


scenario 10

An AC50 descended below FL090 approximately 5 NM from the aerodrome in VMC on a high visual approach for RWY03L to land deep. The AC50 pilot was warned by the TWR controller that the landing clearance would be issued late. TWR then gave permission for GMC to cross traffic over RWY03L and waited for GMC to report the RWY vacated. A JS41 was cleared for take off when the AC50 was on short final (approximately 1.5 nm from the runway). The GMC controller queried the TWR controller about this at about the same time as the pilot of the AC50 enquired from the TWR controller as to the need for him to make an orbit on final. The TWR controller instructed the AC50 to go around instead and the GMC suggested that the AC50 be turned left on a non-standard missed approach to which the TWR controller complied. Separation reduced to 2.8 nm at the time that they passed the same level.

The investigation determined that the TWR controller failed to clear the JS41 for take off at the soonest available opportunity and was surprised

by the close proximity of the AC50 when the aircraft was observed on short final for the first time. The Radar sector failed to advise the TWR controller of the visual approach that the AC50 was cleared on. In addition, the Tower controller returned from extended leave after 4 months and 4 days (124 consecutive days) and did not perform any ATC duties for the duration of this period and therefore the tower validation had expired; the requirement in this case was thus to complete a full tower validation according to Part 65 of the Civil Aviation Regulation.

The controller was subjected to validation training and certification. It was recommended that the requirement for radar training for Aerodrome controllers be reviewed. In addition, it was recommended that the Directive regarding training requirements for PMs and OICs be expanded in order to prevent oversight such as allowing an un-validated staff member to perform control duties.

ControlTower

L3

E

03R

03L

21L

21R

E

E

Aircraft crossed RWY 03L

AC50 on final approach RWY 03L instructed to go-roundand initially maintain RWY HDG, but afterwards instructed to turn out left.

JS41 lined-up RWY 03L for right turn departure, cleared for departure with AC50 on 1.5NM final approach.

DH8C departed RWY 03L onSID turning out right

issue 02 page 21


A Loss of Separation (LoS) occurred in the FAKN TMA between a BE20 and a JS41 when the JS41 descended to the North-East of FAKN airport through the level of the BE20, who had departed from FAKN several minutes before and was to the North West of the airfield routing towards Witbank at the time.

The JS41 inbound to FAKN was advised to expect landing RWY 23 as the surface wind was 240 degrees 13 knots. The BE20 contacted FAKN at 0850Z and advised that they had already started for an IFR flight to FAWB, but no FPL was available and the controller had to locate the FPL before continuing. After coordinating the flight with FAJS Area the controller gave the BE20 taxi instructions for RWY05 and confirmed whether the pilot would accept a tailwind component departure. The pilot accepted and the clearance was issued to climb to FL100 and to maintain RWY HDG until passing 5 500ft before turning left towards Witbank VOR (WIV). The readback of the clearance by the pilot contained a contradiction in that he read back for the aircraft to climb on runway heading to FL100 and to turn left to WIV after passing 5500ft. This ambiguity was not detected and corrected by the ATC and the BE20 was given takeoff clearance immediately following the readback. At 08:56Z the JS41 was released to FAKN ATC and established contact with FAKN at approximately 25 NM from the airfield and approaching from the West. The controller enquired from the JS41 pilot if they were able to accept RWY 05 for landing, but the pilot declined RWY 05 due to the wind and continued to route to PK to establish in a holding pattern for RWY 23. The controller advised both aircraft of each other in the hope that they will acquire each other visually allowing for Reduced Separation between the aircraft while maintaining own separation within visual meteorological conditions. At no time did any of the pilots report the other aircraft in sight and this option therefore did not become available. At 09:00Z the JS41 reached the hold for RWY 23 at FL110, effectively denying the ATC all realistic options of separation between the aircraft as the alternative separation would have required the BE20 to be 5 minutes flying time outbound from the edge of the holding procedure for runway 23. This would have been difficult to determine due to the angle of the outbound track and the ATC would have had little time available to achieve the climb through before the BE20 would have left controlled airspace, once the separation was achieved. The controller then instructed the JS41 to reposition into the holding pattern for RWY 05 instead as it would allow an IFR/IFR Deemed Separation that exists for traffic in the RWY 05 holding pattern and traffic routing outbound to

Witbank VOR (WIV). At 09:02Z the JS41 pilot enquired about the position of traffic observed on the ACAS as the position of the BE20 did not correlate with the observed traffic. The ATC immediately contacted the Lowveld Flight Information Service (SAAF) where radar is in operation that can survey the interior of the FAKN TMA to enquire if LASS has information on the traffic. The BE20 was not to the North West, tracking towards WIV as instructed, but was still maintaining runway heading to the North East. The controller then instructed the BE20 to route direct to WIV from its position. The controller did not realise that the required horizontal separation between the aircraft existed at that time and that the aircraft could have been climbed or descended as required. The controller then set to work establishing a completely different separation utilising outbound tracks (QDR) from the PK NDB beacon that differs with more the 90°. In order to establish this, the BE20 was instructed to establish outbound on a QDR of 320 from PK NDB. The BE20 turned on a South Westerly heading to establish on the QDR 320, nullifying the previously achieved horizontal separation. The controller then instructed the JS41 to establish outbound on the QDR050 and to descend below the level of the BE20. Thereafter the controller cleared the JS41 to execute a visual approach onto RWY 23. The BE20 reported passing QDR335 at approximately the same time and was instructed to climb above the level of the JS41. The intention of the controller was to keep the JS41 in the PK NDB hold while descending, however mistakenly said “QDR” instead of “hold” when instructing the JS41 to do so. The readback from the JS41 indicated that they were leaving the PK hold, as instructed, and proceeding outbound to the North East on QDR 050; however this was not detected by the controller.

The investigation determined that the LoS was the result of the incorrect application of the 90° NDB separation that was compounded by the unintentional routing of the JS41 away from the RWY05 hold. Neither the actual position at the time nor the intended position of the JS41 would have provided the required separation between the two aircraft involved. In addition, it was concluded that the limited navigation infrastructure available at FAKN (NDB, DME and ILS) places an additional burden on the controllers as limited separation possibilities are available to them.

The controller was subjected to remedial training shifts and counselled on the impact a loss of composure has on situational awareness during unexpected events or non-compliance by pilots

scenario 11

issue 02 page 22


scenario 11, cont...and the relationship between mental composure and performance deterioration. Special attention had to be paid to correct RT during the controller's upcoming annual proficiency assessment. Correspondence was sent to the operator of the BE20 explaining the result of the non-compliance to the after departure clearance and the poor quality of pilot RT and readback procedures. In

addition, it was recommended that SD Management develop procedures to be included in the Unit SSI Manual for the use of VDF to assist in monitoring the progress of flights in the TMA. SD Management are to conduct a safety assessment on the requirement of additional navigational infrastructure and/or deemers to support ATM operations in the FAKN airspace.

Will this be blame and shameOR are we actually going to learn from this error?

issue 02 page 23

QDR 320

QD

R 0

50

BE20

1- 2800ft @ 0856Z2- 8000ft @ 0900Z3- FL100 @ 0903Z4- FL100 @ 0907Z

JS41

1- FL145 @ 0856Z2- FL110 @ 0900Z3- FL110 @ 0903Z4- FL110 @ 0907Z

NDB“PK”

1

2

3

4

1

2

3

4

NDB/DME 05 Hold

NDB/DME 23 Hold

NDB/DME/ILS 05 Hold

Approx 11 NM

05

23


PLEASE FORWARD YOUR SUGGESTIONS AND INITIATIVES TO:

WE NEED YOUR [email protected]

The real question that is more applicable to our business is not, to be or not, but

So, how long is a piece of string then? It is a question that is asked not to truly seek the answer, but as a response for the speaker to indicate that the answer is uncertain, relative to one's own perspective, and not entirely definable.

My own answer to the good service question is: When a pilot receives the new duty roster for the next month he/she quickly scans down the column to see how many times over that period they will fly into your airspace just so that they can make use of your service again. Because they know that your airspace is safe; you will speak to them in a professional manner; you will help willingly those who need a little help and also those who are waist deep in the “dwang”; you will not delay them without good reason; their fuel concerns are also your concerns; you will straighten them out when their navi-guessing is a little skew; you will not dent their ego when they “screw up”; you will not destroy their fuel saving efforts by interfering with their descent profile unnecessarily; you won't call them idiots to your colleagues; you will not call them on the radio when they have a sandwich in one hand and a cup of coffee in the other and you won't vector them to intercept the glide path and localiser at the same moment.

“What is a good ATS Service?”

In short, that you can be trusted.

Yes, I know that you as an ATC also want to give your trust to the air crew. You want to know that they won't bust their level; line up on the runway without your approval; complain because they are not #1 in the sequence; slow down to 120 knots at 10 miles from the runway when you instructed them to maintain 160 knots; say to their colleagues that you don't know the first thing about aeroplanes; report ready for an immediate departure and then squat on your runway; that they will read back their instructions; they will use their callsign when transmitting; they will listen out on the frequency when you are talking to them; they will not violate your sacred airspace; they won't tell their passengers the delay was ATC's fault (even if it was) and they won't tell you on frequency when they think your service is poor.

Trust is not easy to earn, either way. It takes a long time to build and it is very easily shattered.

Are you building on the relationship of trust or are you shattering the trust bit by bit?

So in an attempt to improve service and professionalism for the ATCs and Pilots out there, pop us an e-mail and tell us what frustrates you the most about the voice in your headset. Send to:

In short, that they can be trusted.

[email protected]

how long is a piece of string?

issue 02 page 24

by Tinus Olivier

Date post:	28-Jul-2020
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