ec a th i lrp ob u s f y edition 03 w feb. '08 net/safety-netedition3.pdf · ec a th i lrp ob...

edition 03 feb. '08 we catch it all we report it all all about safety

02

safetyinitiative &commitmentawards

03

ATNS safetymanagementsystem...the sms

06

competition time

06

reigningbrain

07

who iscommitted?

08

safetyscenarios:july toseptember2007

we catch it all we report it all all about safety

issue 03 page 02

awards galoreA few awards of recognition were made recently to recognise the safety initiatives and exemplary safety commitment of staff over the past couple of months.

The first award was made to Francois Barwise at FALA for making an unpopular decision in order to ensure safety of customers. The action taken by Mr Barwise is a case in point of someone buying in to the corporate safety culture and who takes ownership of safety management in making a safety decision that may be labelled as an unpopular decision by customers – though ensuring safety at all cost.

On a particular day in August 2007, FALA lost all landline communications with the outside world including the PCUG. All personnel in the TWR were subsequently obliged to use their private cell phones in order to affect start clearances and other co-ordination with adjacent ATSUs as no back-up means ofcommunication was available within the Tower. As a result, Lanseria Airport Management (APM) was notified of the situation and requested to review the requirement for back-up communication.

In the following month, a reoccurrence of this failure resulted in the Acting OIC instructing the personnel in the TWR not to issue any start clearances to any IFR departures due to the unavailability of co-ordination means between FAJS Approach and FALA. In addition, the Acting OIC phoned FAJS Approach from his private cell phone to inform them of the failure and the embargo on starts for IFR traffic. He also offered his personal number for co-ordination of any inbound IFR flights. Numerous delay complaints were received from airport management as well as customers, but the Acting OIC maintained composure in order to ensure safety of the total flying community (The Telkom lines were back in operation after 6 hours).

Editor's note: Since the two occurrences, FALA APM have addressed the risk and issued a cellular phone to the Tower to be used in the event of future communication failures.

The next award was made to Michael Botes from FAKM whom went beyond his job description and daily duties to ensure the safety improvement of the local airspace.

In October 2006, Mr Botes received a phone call from a resident whose daughter was taking flying lessons at FAKM, advising him of an unserviceable obstruction light on top of a mast which was located in the city. The mast was located on a mine dump (approximate radial 035KYV at 3,5DME). In addition, the SAPS helicopter also mentioned the unserviceable obstruction light.

Mr Botes started follow-up actions that stretched over two months, in an attempt to find the responsible party and this lead him to various people working for De Beers,who owned the mine dump and Multichoice, who owned the mast. Due to Mr Botes' continuous follow-up and commitment towards safety, the end result was a notice from De Beers that the mast was non-operational and thus removed on the 20th of November 2007.

Award 2

Award 1

Luke Hawkins (MSA) handing over acheque to Francois Barwise

Michael Botes receiving his chequefrom Zaynub Parker (FAKM OIC)


awards galore, cont...

issue 03 page 03

Although this award was not specifically awarded as a safety award, the fact that a manager takes up staff feedback on his leadership style as a challenge to change and by doing so harnesses the development of a safety culture that is in support of good staff morale, has to be recognised!!

The FABL safety audit afforded staff the opportunity to respond

to what they experienced their leader to be . The response was a manager that was willing to make personal changes based upon “sometimes painful” staff feedback during the diversity workshops of 2005 to lead his staff to new safety frontiers!

Congratulations to Ken Watson! We wish you all of the best on your journey as you develop into the best leader you can be.

(part of Human Factor Safety Audit, ICAO Doc 9806)

We thought it a good idea to run a series of short articles about the ATNS Safety Management System (SMS) to assist our staff in understanding the SMS.

Around the early 1980's the world of aviation came to the conclusion that many of the efforts to improve safety were not effective and a new approach to the safety problem was sought. The “Experts” devised an integrated approach that includes reactive, proactive, and predictive methods that is intended to serve all our safety needs and called it an “SMS”. Some organisations (such as US Coast Guard) were quick to implement SMS and found it to be very useful to improve safety. Well, ICAO took a good look at SMS and decided it is a good thing for Safety. In fact ICAO was so impressed with it they embedded it into the foundation by writing it into the Annexes. Because it is in the Annexes, it is now a requirement for all ANSPs and operators to implement and maintain a Safety Management System in order to ensure safety monitoring, assessment, auditing and promotion. In addition all CAAs are also required to implement and maintain a Safety Management Program as an oversight function of the relevant SMSs within that country.

ATNS implemented the ATNS SMS in September 2006.

Why SMS?

How does the Safety Management System (SMS) fit in with Occupational Health & Safety (OHAS) and our Quality Management System (QMS)?

Award 3

sms 101We thought it a good idea to run a series of short articles about the ATNS Safety Management System (SMS) to assist our staff in understanding the SMS.



Why SMS?





Why SMS?





Why SMS?





Why SMS?


SMS

QMSOHAS

Within ATNS all three systems are interlinked - although each serves a specific purpose, the three systems are also

interdependent and supportive of each other to ensure a safe working environment according to certain pre-determined standards that overflow into an international industry.

Fourth from left, Ken Watson (FABL MATS)receives his cheque from the FABL team


issue 03 page 04

sms 101, cont...ATNS SMS: Our SMS Manual comprises of SEVEN sections and during each forthcoming edition of SAFETY-NET an article will focus upon a section and its relevance to staff:

- Safety Management System Abbreviations, Definitions & References - Safety Management Policy & Scope- Safety Management Organisation- Safety Performance Monitoring

- Safety Assessment - Safety Management System Auditing- Safety Promotion

Below is an excerpt from the SMS Section 2 explaining the ATNS POLICY and SCOPE:

Safety is the first priority in all our ATM system activities. We are committed to implementing, developing and improving appropriate strategies, management systems, processes and procedures to ensure that all our ATMSD activities uphold the highest level of safety performance and meet national and international standards and expectations.

a) Develop and embed a safety culture across all our ATM system activities that recognises the importance and value of effective aviation safety management and acknowledges, at all times, that safety is paramount;

b) Clearly define for all personnel their accountabilities and responsibilities for the development and performance, which includes the safety imperatives;

c) Minimise the risk associated with an aircraft incident or accident to a point which is “As Low As Reasonably Practicable/Achievable”;

d) Ensure externally supplied systems and services that impact upon the safety of our ATMSD operations meet appropriate safety standards;

e) Actively develop and improve our safety processes and procedures to meet user expectations and comply with SARPS (Standards & Recommended Practices);

f) Comply with, and wherever possible exceed, legislative and regulatory requirements and standards;

g) Ensure that all personnel are provided with adequate and appropriate safety information and training, are competent in safety matters and are only allocated tasks commensurate with their skills;

h) Ensure sufficiently skilled and trained resources are available to develop safety strategy and implement policy;

i) Establish and measure our ATM system safety performance against objectives and targets;j) Achieve the highest levels of safety standards and performance in all our ATM activities;k) Continually improve on our safety performance; andl) Conduct safety and management reviews and ensure that relevant action is taken where

required.

We are all responsible for working in a safe manner. The application of an effective Safety Management System is integral to all our ATM system activities with the objective of achieving the highest level of safety standards and expected performance.

The Safety Management System encompasses all the ATMSD activities of ATNS. This includes the management, operational air traffic controllers, aeronautical information management personnel and technical support. Projects and acquisition and commissioning of equipment and systems are

Section 1Section 2Section 3 Section 4 Section 5Section 6Section 7

In this issue we will focus on Section 2.

Policy

Our commitment is to:

Scope


issue 03 page 05

performed in conjunction with appropriate safety assessments and the identification and mitigation of associated risks, including security implications related to the staff, installations and facilities of ATNS. Furthermore this approach is dependant on the support of a safety system that encompasses excellent support in the form of Human Resource and Financial Management as well as Training and Business Development.

Want to know more?

How about some SMS training?

The SMS Manual is available on portal under the icon of “Safety Management”

The ATA is embarking on the development of a Safety Management System (SMS) course during January 2008. Indications are that the program will be aligned to a unit standard and the CDU has identified two possible unit standards that can be utilised in this regard. One of the unit standards forms part of the National Diploma: Air Traffic Control on NQF Level 6 and the other one is included in the National Certificate: Aerodrome Control (NQF Level 5). During the needs analysis phase of the training development, the CDU will determine, in conjunction with M:SA and other role players, which of these unit standards will most adequately address the needs of ATNS and thus the program will subsequently be aligned to the identified standard. Learners who attend and successfully complete the program will then be able to start accumulating credits towards a national qualification on either NQF Level 5 or 6. The planned date for completion of the development is 31 March 2008. In addition, the IATA training schedule presented at the ATA also provides 5 day SMS and Advanced SMS courses for anybody interested in Safety Management.

sms 101, cont...

safety culture

management philosophy

continuousimprovement of

safety performance

safetymonitoring

safetyassessment

safetyauditing

safetypromotion

supporting organisationalrequirements

Graphical representation of SMS encompassing generic safety activities

safetypolicy


issue 03 page 06

competition time

Can you identify this airport? Please provide the name and ICAO indicator of the airport as well as the country where this airport is located. E-mail your answers to and stand a chance to win a cool corporate gift.

: This airport is served by 11 scheduled airlines with its single RWY12/30 and is adjacent to the world's 7th largest natural harbour.

[email protected]

CLUE

The reigning brain of ATNS for the October 2007 edition is (ATSA FAWB). WELL DONE - your corporate pen & pencil set is on its way!!

There were 3 correct entries, but unfortunately there can only be one winner. Well done to and as well! Thank you to all those who entered the competition, some of

you had the airport name correct, but remember the competition question was: “Identify the location and the name of the airport”. The answer was: Bisho Airport (FABE) in the Eastern Cape.

BONGANI TSHABALALA

Nicolas Taylor Hendrik Hubbard

current reigning brain of ATNS

who is the reigning brain?

Reproduced with permission of jeppeson sanderson, inc. Not for navigational use. ©jeppeson sanderson, inc. 2007.

The SAFETY-NET is also aiming at creating a platform for staff to have a safety voice within ATNS. Colin Bryant received a corporate trolley bag for his letter to the SAFETY EDITOR that highlighted a safety risk within the FAJS Area environment.

Colin's letter to his Unit Managers and the SAFETY-NET highlighted a culmination of various risk factors ranging from staffing to training and frequency combinations specifically affecting night shift operations on various FAJS Area sectors.

Note from the Editor: Thank you for your letter Colin and your willingness to share your safety concern. Although this was an inherited safety risk, the FAJS unit management is in the process of mitigating the identified risks.

Don't forget to forward us your creative safety ideas or any safety concerns! 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.

[email protected]

Johnny Smit (FAJS MATS), left, andLuke Hawkins (MSA) (right) handing

over a corporate travel bag to Colin Bryant.


issue 03 page 07

At 1001 UTC a CRJ was cleared inbound by the FACT Area West controller to WY then CTV to comply with a prescribed procedure published by NOTAM. The controller used the RT “for the NOTAMed procedure VOR/DME Approach runway 01”. The pilot readback the inbound clearance by stating “for the VOR approach runway 01”. The omission of the reference to the “NOTAMed procedure” effectively changed the inbound clearance for the aircraft to route direct to CTV and not to comply with the procedure as published in the NOTAM (requiring the aircraft to turn south as it approached the aerodrome).

At 1030 UTC the CRJ was approximately 10NM to the North East of the aerodrome still routing directly towards CTV. The aircraft was by now under the control of the FACT Approach controller, whom noticed that the aircraft did not turn left onto a southerly heading for a downwind position as was

As always, the SAFETY-NET aims to be the safety voice of ATNS managers and staff alike. ATNS's Nkokeng Morufane (EM: SHR) shared a few words on his commitment towards improving safety within ATNS: “Safety is and will remain one of our key business imperatives within the aviation industry and in particular to ATNS. As

expected. The STCA activated between the CRJ and a departing MD82 off RWY01 and the separation reduced to 3.5NM and 100ft. The controller instructed the CRJ to turn left and queried the pilot on the missed turn, but he did not pass traffic information to either aircraft.

The investigation determined that the procedure as employed to use a NOTAM procedure as a replacement to the STAR resulted in the procedure being complicated from the perspective of an aircraft's operation, as this procedure required extensive manual manipulation of the FMS. The revised procedure as published by NOTAM was not available on the DATIS due to symbol recognition limitations.

It appears that sufficient time did however exist for the crew to be aware of the expected procedure on their arrival into the FACT FIR. The LoS was

Executive Manager - SHR, I am committed to play a strategic role in aligning and implementing HR policies and practices that will support and promote all safety initiatives in the business. Paramount to this, is cultivating within the SHR Service Delivery environment, a high performance culture that will exceed expectations in order to obtain and sustain high levels of employee satisfaction.”

safety events: july to september 2007- scenario 1

.

.

3.5NM / 100ft

CRJ was turned left by theApproach controller, but stillactivated STCA with departing MD82.

NOTAMed VOR / DME approachRWY 01 from Wolseley.

safety - who is committed?


At approximately 0715Z three JS41 type aircraft were inbound to FAJS via STV. All three aircraft were estimating the STV beacon within 2 minutes of each other. The respective aircraft were inbound to FAJS were as follows:

a) JS41 Number 1 inbound from FAPM maintaining FL200;

b) JS41 Number 2 inbound from FAUT maintaining FL190;

c) JS41 Number 3 inbound from FDMS at FL160.

For sequencing into the FAJS TMA, the Radar sector required 15NM separation at the time. The Maestro sequencing tool was not available due to the unavailability of the GRIB winds information required on the EUROCAT system. To enable the Area controller to achieve the 15NM spacing, radar vectoring to JS41 Number 2 and JS41 Number 3 had to be applied in order to facilitate sequencing in

behind JS41 Number 1. Therefore JS41 Number 2 was instructed to fly a heading of 035° in order to intercept R180 STV and JS41 Number 3 was instructed to fly a heading of 270° to intercept R145 STV. The heading allocated to JS41 Number 2 would have positioned the aircraft approximately 5NM behind JS41 Number 1. As JS41 Number 1 was ahead of the other two aircraft, the aircraft had to be descended below JS41 Number 2 in order to assist Approach in sequencing the aircraft. The controller changed the CFL (Cleared Flight Level on EUROCAT System) on JS41 Number 1 to FL180, however he did not issue the instruction for descent to the pilot. By means of the velocity vectors and the Route Function, the controller determined that there was inadequate separation at the time and refrained from instructing the aircraft to descend, however the controller never changed the CFL back to the cruising flight level. Thereafter JS41 Number 1 automatically commenced the descent without an ATC clearance, as the two aircraft were 10.2NM apart

scenario 2

issue 03 page 08

FA

JS

TM

ASTANDERTON“STV”

Pilot error with lesson to be learnedfrom ATC removing memory cues fromsystem.

JS41 inbound from FDMS FL160 instructed to fly HDG 270 to interceptR-145 STV.

JS41 inbound from FAPM FL200 commenced without ATC clearance.

JS41 inbound from FAUT FL190 instructed to fly HDG 035 to interceptR-180 STV.

attributed to ATC operational error due to the incorrect readback not being detected by the Area controller.

The Area controller was subjected to counselling and a dual shift combined with a proficiency assessment that focussed upon maintaining radio guard and listening to ensure correct readbacks.

Service Delivery (SD) Management was requestedto review the implementation of the NOTAMed procedure. FACT was requested to develop objectives for annual continuation training that includes simulated exposure to LoS, conflict resolution, ensuring correct readbacks and the passing of essential traffic information.


issue 03 page 09

scenario 3

A BE20 departed FAGM at time 0412Z for FACT, requesting FL270 (incorrect semi-circular flight level), with a flight plan route via RAGUL UQ10 towards APMIN. At 0419Z the BE20 contacted FAJS Area South West on frequency 128.3MHz while still on track to position RAGUL and was instructed by Area to climb to FL260, routing direct to APMIN. ZSNKC maintained a rate of climb less than 1000' per minute until reaching FL260. The two area sectors were combined as per operational hours stipulated in the Pool roster and the operational frequency 128.3MHz was coupled with that of the Area South East frequency of 128.15MHz on the VCCS. A B738 departed FAJS at time 0420Z requesting FL350 for FACT and routing via RAGUL UQ10 to exit the Area South West sector at position APMIN. FAJS Area South instructed the B738 to climb to FL350 on first contact and without any restrictions. The B738 continued with a ROC of 3000ft per minute until passing FL240 when the ROC decreased to approximately 1500ft per minute. At time 0434Z, separation reduced to 5.7NM as the B738 passed north of the BE20 at a position 65NM south west of JSV. The B738 was passing FL250 and the BE20 was passing FL254 (both aircraft climbing). The STCA alert activated, but the first instruction for conflict resolution was only passed 26 seconds later when the student controller (after 70 hours dual) instructed the B738 to turn right onto a HDG of 270°. Thereafter essential traffic information was passed to the B738, but not to the BE20 as the B738 was already passing FL270 at that time.

and the STCA activated. The controller ignored the STCA and thereafter developed doubt whether an instruction to descend was issued. This was followed by an instruction to the aircraft to descend to FL180. Separation reduced to 7.3NM and essential traffic information was not passed.

The safety event is considered as non-ATS related, as the investigation determined that the crew of JS41 Number 1 commenced descent on two occasions without any ATC instruction. However, significant lessons can be learnt from this event as the controller on three occasions manipulated the CFL and electronically acknowledged the change in FL (effectively removing the memory cue alert: CLAM) without actually instructing the aircraft to descend, nor was essential traffic information passed or the level infringement challenged.

The controller was subjected to counselling, a review of the radar recording of the safety event and a proficiency assessment that focussed upon his interaction with the EUROCAT system.

SA AirLink was advised of the outcome of the ATNS investigation and the safety officer and pilots involved were invited to review the radar recordings together with the controller involved.

Service Delivery (SD) Management were requested to ensure that continuation training was developed for controllers that will focus upon conflict resolution and the passing of essential traffic information. In addition, SD and the EUROCAT System Administrator were requested to investigate the risks involved with false alerts and alert differentiation and to communicate an action plan to staff in order to mitigate complacency amongst controllers.

Primary radar coverage is limited to 60NM JSV. Minimum lateral separation within 60NM from JSV is 5NM and outside of 60NM JSV the separation is to be increased to 10NM or else 1000ft vertical separation has to be applied below FL290.

The investigation determined that the LoS was primarily caused by the loss of situational awareness by the student as well as the OJTI. In addition, a contributing factor was the OJTI's task shift away from the ASD as he was completing an inscription in the student's training log. Failure to provide essential traffic information did not increase the existing risk to the LoS, however this will impact adversely on ATNS liability in the event of a more critical scenario or catastrophe.

The OJTI and student were subjected to a counselling session and the student returned to OJT. The OJTI was subjected to a proficiency assessment before re-commencement of controlling duties. On request of the OJTI, a 2 month sabbatical from providing OJT was afforded to the OJTI and on the return to OJTI duties, an OJTI proficiency assessment conducted by the PM and an Instructor from the ATA was completed.

Technical Services were requested to provide feedback to operational staff on the progress made wrt to the serviceability of the GRIB wind function.

Service Delivery (SD) Management was requested to review the training process and objectives within FAJS Area North/South Pool with specific


scenario 3, cont...

issue 03 page 10

Only the two relevant aircraft were on frequency at the time of the safety event. A MD82 called FAPE Approach on departure RWY08 at 1557Z and was instructed by the controller to climb to FL150 and to route to position ITKIT (SID termination point) “when ready”. A CRJ was inbound to FAPE from FADN. At 1601Z the TOP function (Time of Passing) was applied by the Approach controller to determine the crossing distance between the MD82 and the CRJ. The TOP function indicated a distance of 7.3NM at the passing point. Due to the withdrawal of the FAPE Primary Radar, standard separation within the TMA was increased from 5NM to 10NM. At 1602Z an ICM (Inter Console Message) was sent from the FACT East Area

controller that indicated FL210 was approved for the MD82. The FAPE controller responded by instructing the MD82 to climb to FL210 and handed the aircraft to FACT Area East at 1602Z. The CRJ contacted FAPE Approach at 1603Z maintaining FL160. At the time the MD82 was still maintaining FL150. The Approach controller passed traffic information on the MD82 to the CRJ and instructed the CRJ to descend to 4500ft. Separation reduced to 7.3NM as the CRJ passed FL150.

The investigation determined that both controllers had correctly identified the conflict prior to the LoS. The FACT Area East controller

progress assessments of students, had to be included as well.

Furthermore, it was recommended that the SSIs be updated to reflect the separation requirement for Area North/South within and outside of 60DME JSV. Finally, a communiqué was prepared for all units on the due process of investigations and the potential outcomes, i.e. errors vs violations and the guarantee of job safety after committing an error.

scenario 4

ControlTower

03R

03L

21L

21R

H

H

RAGULWKV R-240/50

“WKV”

R-2

40

“JSV”FALA TM

A

FAJS

CTR

“RAV”

FAJS

TM

ARAGUL

1A

APMIN

5.7NM

Primary Radar coverage limit.Lateral separation minima change over from 5NM to 10NM.

Converging track of B738 on standard routing to FACT, passing FL254 climbing FL350.

BE20 enroute RAGUL to APMIN,rerouted direct APMIN passing FL250 climbing FL260.

reference to increasing the learning curve potential (for example OJTI matching; task specific training, validating on 1 sector at a time; increased OJTI contact time; sector specific simulator training, etc. (student familiarisation as well as continuation training). OJTI applications of training objectives were to be included in the review as well. In conjunction with the aforementioned review, action plan development and implementation with respect to addressing shortcomings identified during


issue 03 page 11

had wrongly assumed that he had in fact handed the CRJ to FAPE Approach earlier thus making the period that the CRJ was incommunicado significantly longer than that of the MD82. This was only rectified by a prompt from the crew of the CRJ. Once the simultaneous handover had occurred there was still an opportunity to prevent the LoS had both controllers reverted to the LOA and levelled the traffic off at the specified flight levels as per SOP. Furthermore it was determined that the FACT controller failed to provide essential traffic information and to apply standard coordination procedures. The FAPE controller accepted a non-proceduralised coordination method and failed to ensure that separation was maintained. In addition, the complacency of both controllers to take responsibility and/or control of the situation, combined with the system failure with regards to controller perception and changes in task environment (doubling of required separation requirement) as well as the removal of a controller memory cue (STCA switched off in error after a data set upgrade) were considered as contributing factors.

Both controllers were subjected to counselling sessions, dual shifts and proficiency assessments . Serv ice Del ivery (SD) Management was requested to review the application of the ICM tool in terms of legalities within the ICAO requirement of inter- and intra ATSU liaison as well as the non-standard co-ordination applied by the controllers. In addition the STCA settings were to be rectified as a matter of urgency. Operational staff were sensitised to the importance of utilising breaks for the purpose of relaxation and recovery of mental performance abi l i ty/si tuat ional awareness. It was further suggested that staff be sensitised to the liability involved on individual and corporate level in the event of mental overload resulting in an accident where the break was not administrated according to human performance requirements. Finally, staff were reminded of the importance to be relieved from position immediately following a safety event as part of an initiative to manage trauma recovery after a safety event and the subsequent corporate liability (awaiting approval to be included in SMS Section 4).

scenario 4, cont...

FAPE CTR

FAPE TMA-A

FAPE TMA-B

FAPE TMA-E

FA

PE

TM

A-C

FA

PE

TM

A-D

ITMIT

GENOX

7.4NM

CRJ handed over maintaining FL160,provided with traffic information andthen instructed to 4500ft.

MD82 maintaining FL150 (liaisonvia ICM) then instructed to FL210.

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