The AFAP has recently surveyed its pilot members, consulted with pilot representatives, the Air Traffic Control (ATC) union, the Australian Transport Safety Bureau (ATSB) and requested freedom of information (FOI) material from the regulator, the Civil Aviation Safety Authority (CASA). For the reasons outlined in the material below we have reached the following concerning conclusions:
- Airservices Australia (ASA) is struggling with severe staffing shortages of air traffic controllers, leading to overreliance on contingency measures that introduce safety risks. These shortages were set up well before the pandemic and are not primarily caused by short notice sick leave.
- The frequent and unplanned use of procedures like “Traffic Information Broadcast by Aircraft” ((TIBA), TIBA is a contingency measure used in controlled airspace when infrastructure or resourcing has failed) is unsustainable, less safe and indicates a lack of robust air traffic management systems and resources.
- Incidents in Australia and internationally point to the critical importance of effective airspace management for aviation safety. These lessons were built into the ATC system and removal of staffing resilience opens the risk of catastrophic outcomes.
- ASA faces challenges with procurement practices, budget overruns, and toxicity within the organization's culture.
- There are questions about the adequacy of oversight, planning and funding by ASA's executive team and board to properly manage Australia's airspace.
Recommended actions:
- The government should intervene to address dysfunction within ASA and bring the organisation back under proper public control.
- An urgent recruitment drive and investment in training is needed to address staffing shortages of air traffic controllers and build resilience back into the organisation.
- ASA must improve air traffic management systems and procedures to minimize reliance on unsafe contingency measures like TIBA.
- Stronger oversight and governance should be implemented to hold ASA's executive team and board properly accountable for airspace management outcomes.
- An independent review of ASA's staffing levels, culture, procurement practices and budgeting should be conducted to identify and implement necessary reforms.
The overarching goal should be to restore the safety and effectiveness of Australia's airspace management system. Funding and leadership must prioritise initiatives that enhance aviation safety and efficiency, with clear consequences for non-compliance. Action is needed to return ASA to a position where it can properly manage one of Australia's critical transport assets. The safety of Australia's skies depends on it.
Airservices Australia's Airspace Management Under Pressure
ASA, the government corporation responsible for managing Australia's airspace, has come under scrutiny in recent years over its ability to effectively manage the air traffic control system. Reports of staffing shortages, use of contingency measures, and contract issues point to systemic problems that raise safety and financial concerns.
ASA manages over $5 billion of air navigation infrastructure and tracks more than 50,000 flights per year through some of the world's busiest airspace. However, it has faced budget overruns, delays to modernisation projects, and resourcing challenges that pre-date the COVID-19 pandemic. (https://www.aph.gov.au/Parliamentary_Business/Senate_estimates/rrat/2018-19_Additional_estimates/Report/c05)
The Problems:
Staffing - ASA has struggled with a lack of appropriately qualified air traffic controllers, resulting in the frequent use of temporary restricted airspace and broadcast-by-aircraft procedures to cover for gaps. Regulator CASA is concerned this is becoming unsustainable.
During the COVID-19 pandemic, ASA offered a retirement incentive scheme worth up to $400,000 for air traffic controllers over age 56. They were warned this would leave insufficient staff when traffic returned, but ASA recruited new trainees to fill the positions. However, air traffic controllers are now taking unplanned leave at record levels, causing disruptions and delays. ASA is now undertaking an expensive recruitment drive for 80 new controllers, the controllers state that many more are needed.
Contingency measures - The widespread and regular use of contingency measures across the system are introducing additional risks. Issues have been reported around inconsistent application, insufficient notice, and confusion among pilots and controllers.
Repeated short notice use of TIBA procedures in Australian airspace introduces risks such as:
- -Unnotified airborne holding, not accounted for in a flight plan or fuel plan
- -Increased workload
- -Reduced situational awareness
- -Risk of human error
- -Decreased efficiency
- -Inadequate training and familiarity with TIBA
- -Unclear coordination between adjacent airspace sectors.
Contracts - An audit found ASA's procurement of services from the International Centre for Complex Project Management during the OneSKY modernisation tender process lacked transparency, oversight of conflicts, and value for money. The project remains over budget.
Program Accelerate - A cost-cutting program led to 900 redundancies. While it helped improve short-term profits, it may indicate a lack of planning for major projects. Budget overruns on OneSKY persist despite the cuts.
Concerns stemming from these airspace restrictions have been raised with Airservices and CASA on multiple occasions. ATSB REPCON reports RA2022-00038, RA2022-00045, RA2023-00053 and soon to be published RA2023-00098 refer.
ATC staff reports show Sydney Airport frequently operates without an air traffic manager in charge. FOI and ASA/CASA documents reveal at least 70 instances of shortages from July to November 2022, with periods of up to 8 hours without a manager. Training of new staff has been reduced from the normal 18 months to 12 months with those new controllers often having no experienced supervisor overseeing their work.
The Responses:
ASA acknowledges some issues but disputes some specifics. It is undertaking measures to improve procedures and consulting stakeholders.
CASA views ASA's contingency practices as unsustainable and is working with ASA through surveillance, enforcement and consultation to address underlying drivers and risks.
Key Issues:
ASA's CEO, board and executive team need to be held to account. The corporatisation experiment has failed and ASA needs to be brought back under proper public control.
ASA's recruitment drive faces an uphill battle due to its history of toxic culture, workplace scandals and poor reviews as an employer.
Proper funding, staffing, planning and transparent oversight is urgently needed to resolve issues and restore confidence in Australia's airspace management. The safety of passengers and flight crews relies on a well-functioning air traffic control system.
Lost Airspace lessons and the use of TIBA
TIBA is a contingency procedure used when Air Traffic Services (ATS) are temporarily unavailable or when the provision of ATS is not possible due to limited infrastructure. TIBA procedures are designed to provide a minimum level of safety and efficiency in such situations.
While it's difficult to pinpoint specific countries that routinely use TIBA, certain regions and countries may be more prone to using TIBA procedures due to reasons such as:
1. Remote or sparsely populated areas: In some parts of the world, especially in remote, sparsely populated regions, air traffic services may be limited or non-existent. In these cases, TIBA procedures can be used to provide some level of safety and efficiency for aircraft operating in the area. Normally low-density GA aircraft not high capacity jet aircraft.
2. Natural disasters: Countries prone to natural disasters like earthquakes, hurricanes, or volcanic eruptions may experience temporary disruptions in their air traffic services. In such cases, TIBA procedures can be employed until normal ATS operations are restored.
3. Conflict or political instability: Countries experiencing conflict or political instability may have disruptions in their air traffic services due to damaged infrastructure or lack of resources. TIBA procedures can be used as a temporary measure to maintain safety in the airspace during these situations.
4. Technical issues or equipment failure: When technical issues or equipment failures cause disruptions in air traffic services, TIBA procedures can be used as a contingency until the problems are resolved and normal operations can resume.
It's important to note that the use of TIBA procedures is generally temporary and not a long-term solution for air traffic management. The goal is to restore normal air traffic services as soon as possible to maintain optimal safety and efficiency in the airspace. Australia should not be a country experiencing regular TIBA contingency of its airspace management.
Lessons from past international airspace incidents emphasize the importance of air traffic management for aviation safety. Incidents involving issues like miscommunication, outdated equipment, and procedural errors highlight the need for robust airspace systems and constant improvement. Australia has experienced its own incidents related to airspace management, underscoring the complexities involved and the critical role of air traffic controllers.
Here is a list of historic international aviation accidents and incidents where airspace management was a major contributing factor:
- Tenerife Airport Disaster (1977)
- Charkhi Dadri Mid-Air Collision (1996)
- Uberlingen Mid-Air Collision (2002)
- Hudson River Mid-Air Collision (2009)
- San Francisco International Airport Near-Miss (2017)
- Zagreb Mid-Air Collision (1976)
- Cerritos Mid-Air Collision (1986)
- Linate Airport Runway Collision (2001)
- New York City East River Helicopter Collision (2018)
- Madrid Runway Incursion (2019)
Notable Australian-related airspace incidents:
- Sydney Airport Airprox incident involving two Qantas aircraft (2021)
- Sydney Airport Loss of separation between two Qantas aircraft (2018)
- Sydney Airport Loss of separation between two B737 jets (2023)
These incidents emphasize the critical role that airspace management plays in aviation safety. The lessons learned from these accidents and incidents have led to improvements in air traffic control procedures and technology to enhance the safety of aviation operations worldwide. They highlight the importance of effective airspace management and underscore the need for continuous improvements in air traffic control procedures, resourcing, technology, and training.
These incidents serve as valuable reminders of the complexities involved in airspace management and the critical role that air traffic controllers play in maintaining safe and efficient operations. The lessons learned from these incidents contribute to the ongoing efforts to enhance aviation safety in Australia and around the world. They highlight the importance of proper airspace management, air traffic control procedures, and communication between pilots and controllers. They also emphasize the need for ongoing improvements in aviation safety to minimize the risk of incidents in the future.
Repeated and short-notice implementation of contingency measures like TIBA (Traffic Information Broadcast by Aircraft) in Australian airspace can introduce several risks and challenges to aviation safety and efficiency. Some of these risks include:
1. Increased workload for pilots and air traffic controllers: The use of TIBA procedures requires pilots to broadcast their position, altitude, and intentions more frequently. This can increase the workload for pilots and air traffic controllers, who must monitor and process additional information in an already demanding environment.
2. Reduced situational awareness: TIBA procedures rely on pilots broadcasting their information and other pilots monitoring and interpreting that information. However, the lack of centralized air traffic control services can lead to reduced situational awareness, increasing the risk of miscommunication or misunderstanding between pilots.
3. Risk of human error: With the increased reliance on pilots for self-separation and the additional workload, the risk of human error could increase. This may result in situations where pilots might misinterpret or miss essential information, potentially leading to loss of separation or near-collisions.
4. Decreased efficiency: TIBA procedures can lead to decreased efficiency in airspace management, as pilots may need to make more significant adjustments to their flight paths or altitude to maintain separation from other aircraft. This could result in increased fuel consumption, longer flight times, and increased workload for pilots and air traffic controllers.
5. Inadequate training and familiarity with TIBA procedures: If TIBA procedures are used infrequently, pilots and air traffic controllers may not be as familiar with them, which could lead to confusion and reduced effectiveness during implementation. Regular training and practice with TIBA procedures are necessary to ensure that both pilots and controllers can respond effectively in contingency situations.
6. Unclear coordination between adjacent airspace sectors: In cases where TIBA procedures are implemented in one airspace sector but not in adjacent sectors, there could be confusion and potential conflicts at the boundaries between these sectors. This could lead to misunderstandings and a higher risk of incidents or accidents.
The AFAP recently surveyed its Australian based pilot members on air traffic delays, key themes from the survey results are here : ATS survey report June 2023
A. There are frequent delays and holding beyond published times, especially into major airports like Sydney, Melbourne and Perth. Many of these delays are unnotified until airborne. This is causing issues like increased fuel consumption, flight crew fatigue and disruption to passenger schedules.
Respondents reported frequent delays and holding beyond published times, especially into major airports.
• 31% of pilots experienced delays multiple times a month
B. TIBA airspace is seen as unsafe and inefficient by most pilots. There is a lack of adequate notification for TIBA activations. Better communication and mapping of TIBA areas is needed.
• 72% of pilots report having an efficiency of flight issue because of contingency measures
C. Some airports are frequently operating on CTAF (Common Traffic Advisory frequency) procedures within published tower hours due to staff shortages. This is seen as unsafe for high-capacity air transport operations.
• 44% of pilots are encountering CTAF contingency monthly or more, with 15 % reporting traffic proximity or separation issues in the last 6 months.
D. Pilot safety reports are not being assessed by the ATSB because they a deemed below the mandatory reporting threshold. This means the frontline user (pilots) safety concerns are not being considered.
• 47% of pilots report that they are unsure of whether their operator is reporting occurrences of unpublished traffic holding
To mitigate these risks, it is essential to invest in robust air traffic management systems, proper training, and effective communication between pilots and air traffic controllers. The use of TIBA procedures should only be a temporary measure, and efforts should be made to restore normal air traffic services as soon as possible to maintain optimal safety and efficiency in the airspace.
Expanded list of historic international aviation accidents and incidents where airspace management was a major contributing factor:
1. Tenerife Airport Disaster (1977)
- Date: March 27, 1977
- Location: Tenerife, Canary Islands, Spain
- Summary: The deadliest aviation accident in history, involving two Boeing 747s, KLM Flight 4805 and Pan Am Flight 1736. The accident occurred when the KLM aircraft initiated takeoff while the Pan Am aircraft was still on the runway. A combination of factors, including poor visibility, miscommunications, and inadequate air traffic control procedures, contributed to the accident. The collision resulted in 583 fatalities.
https://www.faasafety.gov/files/gslac/courses/content/232/1081/finaldutchreport.pdf
2. Charkhi Dadri Mid-Air Collision (1996)
- Date: November 12, 1996
- Location: Charkhi Dadri, Haryana, India
- Summary: A mid-air collision between Saudi Arabian Airlines Flight 763 (Boeing 747) and Kazakhstan Airlines Flight 1907 (Ilyushin Il-76) resulted in the loss of 349 lives. The accident occurred due to inadequate separation of the two aircraft by air traffic control, along with language barriers and lack of modern equipment for airspace management.
https://www.baaa-acro.com/sites/default/files/2020-12/HZ-AIH.pdf
3. Uberlingen Mid-Air Collision (2002)
- Date: July 1, 2002
- Location: Überlingen, Germany
- Summary: A mid-air collision between a Bashkirian Airlines Tupolev Tu-154 and a DHL Boeing 757 cargo aircraft resulted in the deaths of all 71 people on board both aircraft. The accident was caused by human error, miscommunications, and shortcomings in the air traffic control system, including controller fatigue and outdated equipment.
https://www.faa.gov/lessons_learned/transport_airplane/accidents/RA-85816
4. Hudson River Mid-Air Collision (2009)
- Date: August 8, 2009
- Location: Hudson River, New York City, USA
- Summary: A mid-air collision between a Piper PA-32R aircraft and a Eurocopter AS350 helicopter resulted in nine fatalities. The accident was attributed to limitations in the "see and avoid" concept in a congested airspace, along with inadequate communication between the controllers responsible for the airspace.
https://www.ntsb.gov/investigations/Pages/ERA09MA447.aspx
5. San Francisco International Airport Near-Miss (2017)
- Date: July 7, 2017
- Location: San Francisco, California, USA
- Summary: An Air Canada Airbus A320 aircraft nearly collided with four aircraft waiting on the taxiway at San Francisco International Airport after attempting to land on the taxiway instead of the assigned runway. The incident was attributed to pilot confusion, nighttime visual illusions, and lack of air traffic controller intervention. The aircraft descended to within 59 feet of the ground before initiating a go-around. No fatalities occurred in the incident.
https://www.ntsb.gov/investigations/Pages/DCA17IA148.aspx
6. Zagreb Mid-Air Collision (1976)
- Date: September 10, 1976
- Location: Vrbovec, near Zagreb, Croatia
- Summary: A mid-air collision occurred between British Airways Flight 476 (Hawker Siddeley Trident) and Inex-Adria Flight 330 (McDonnell Douglas DC-9). The accident resulted in 176 fatalities. The primary cause was a procedural error by the air traffic controller, who failed to maintain the required vertical separation between the two aircraft.
https://www.gov.uk/aaib-reports/9-1982-british-airways-trident-g-awzt-and-inex-adria-dc9-yu-ajr-10-september-1976
7. Cerritos Mid-Air Collision (1986)
- Date: August 31, 1986
- Location: Cerritos, California, USA
- Summary: A mid-air collision between Aeroméxico Flight 498 (McDonnell Douglas DC-9) and a Piper PA-28 Archer resulted in the deaths of all 67 people on both aircraft and 15 people on the ground. The accident was caused by pilot error, inadequate air traffic control procedures, and limitations in the radar system used for airspace surveillance.
https://www.ntsb.gov/safety/safety-recs/recletters/A87_96_98.pdf
8. Linate Airport Runway Collision (2001)
- Date: October 8, 2001
- Location: Milan Linate Airport, Milan, Italy
- Summary: A runway collision occurred between Scandinavian Airlines Flight 686 (McDonnell Douglas MD-87) and a Cessna Citation CJ2 business jet. The accident, which resulted in 118 fatalities, was caused by a series of errors, including poor visibility, incorrect taxi instructions, and inadequate ground radar equipment.
https://www.havkom.se/assets/reports/Swedish/FINALREPORTA-1-04Linate.pdf
9. New York City East River Helicopter Collision (2018)
- Date: March 11, 2018
- Location: East River, New York City, USA
- Summary: A Eurocopter AS350 helicopter operated by Liberty Helicopters crashed into the East River, killing all five passengers on board. The accident was attributed to the pilot's failure to maintain adequate clearance from a construction crane and the lack of air traffic control oversight of the congested airspace.
https://www.ntsb.gov/investigations/AccidentReports/Reports/AAR1904.pdf
10. Madrid Runway Incursion (2019)
- Date: February 21, 2019
- Location: Adolfo Suárez Madrid-Barajas Airport, Madrid, Spain
- Summary: An Air Canada Boeing 787-9 aircraft had to initiate a go-around after an EgyptAir Boeing 737-800 entered the active runway without clearance. Air traffic control (ATC) had cleared the EgyptAir aircraft to cross the runway, but the pilots did not confirm the instruction and proceeded onto the runway. The ATC controller's workload, lack of situational awareness, and inadequate communication contributed to the incident. No injuries or fatalities occurred.
https://www.mitma.gob.es/recursos_mfom/comodin/recursos/in-041-2022_final_report_nm.pdf
Notable Australian-related airspace incidents:
1. Airprox incident involving two jet aircraft (2020)
- Date: September 28, 2020
- Location: Sydney, Australia
- Summary: Two planes, a Boeing 787 and an Airbus A330, were involved in an airprox incident, with the two aircraft coming close to each other on departure from Sydney Airport. The aircraft departed runway 34L in sequence following the standard instrument departure. During the departure, the following aircraft climbed faster than the controller anticipated and turned towards the next waypoint inside the preceding aircraft, resulting in a loss of separation. There were no injuries or damage to the aircraft, and both flights continued to their respective destinations. The ATSB also found that the design of the DEENA SEVEN SID did not provide a positive method of providing separation assurance to aircraft with different performance characteristics and called for a redesign of the SID.
https://www.atsb.gov.au/publications/investigation_reports/2022/aair/ao-2022-047
2. Loss of separation between two Qantas aircraft (2018)
- Date: Aug 5, 2018
- Location: near Sydney Airport, Australia
- Summary: an Airbus A330-300 (A330) aircraft, registered VH-EBJ and operated by Qantas Airways, was cleared by air traffic control (ATC) for take-off from runway 34 right (34R) at Sydney Airport, New South Wales. At that time, a Boeing 737-800 (737) aircraft, registered VH‑VZO and operated by Qantas Airways, was on final approach to the same runway. controller assessed that there would be insufficient runway spacing between the aircraft and instructed the 737 flight crew to ‘go around’. As the 737 flight crew conducted the missed approach, a loss of separation occurred between their aircraft and the departing A330. Flight data showed that separation between the aircraft reduced to about 0.43 NM laterally and about 500 ft vertically. The Australian Transport Safety Bureau (ATSB) investigated the incident, which resulted in recommendations for improved air traffic control procedures and training and redesign of standard instrument departures.
https://www.atsb.gov.au/publications/investigation_reports/2019/aair/ao-2019-041
3. Loss of separation between two B737 jets (2023)
- Date: April 29, 2023
- Location: near Sydney Airport, Australia
- Summary: The ATSB is investigating a close proximity event involving 2 Boeing 737 aircraft, registered VH-VZM and VH-VZW, at Sydney Airport, New South Wales on 29 April 2023. Both aircraft were using runway 16L: VH-VZM departing and VH-VZW arriving. The ATSB investigation is continuing will include further analysis of operational documentation, training practices, flight recorder and air traffic surveillance data, and related occurrences.
https://www.atsb.gov.au/publications/investigation_reports/2023/report/ao-2023-022