[Peetwo]

Is it just me?

Yesterday the ATSB released their final 'Short Investigation Bulletin' for the year - Aviation Short Investigations Bulletin - Issue 45. At the top of the SIBs page it states:

 "..Released periodically, the Bulletin provides a summary of the less-complex factual investigation reports conducted by the ATSB. The results, based on information supplied by organisations or individuals involved in the occurrence, detail the facts behind the event, as well as any safety actions undertaken. The Bulletin also highlights important Safety Messages for the broader aviation community, drawing on earlier ATSB investigations and research..."

This is Dolan speak (weasel words), for.. "we have limited resources to spend on full blown incident (versus accident) investigations, so if a desktop investigation can be conducted  which will conserve resources then that is what we will do."

However I am not sure if pushing that 'Short Investigation' definition to include a 'serious incident' where a near collision involving a 60 tonne Orion P3-C aircraft and a Schweizer 269C helicopter, over a built up area necessarily justifies a limited, short investigation budget - AO-2015-101.

On sighting the Orion, the pilot of JXO had immediately initiated a climb to avoid a collision, and estimated the Orion passed about 100 ft below. On hearing the controller pass the Orion as traffic to the pilot of JXO, the Orion crew immediately became concerned about the helicopter’s proximity, and looked for it. The co-pilot (non-flying pilot) of the Orion sighted JXO, assessed there was a risk of collision, and called ‘go low, go low, go low’. The captain (flying pilot), also sighted JXO, and increased the rate of descent to pass beneath the helicopter. The Orion crew estimated that JXO passed about 50 ft directly above the Orion, and were concerned it may collide with the Orion’s vertical tail fin. On the radar SDD, at 1514:25, both aircraft appear in the same position at 600 ft (Figure 6).

It is evident, from the safety actions section of the report, that the RAAF are taking this incident very seriously:

Safety action

Whether or not the ATSB identifies safety issues in the course of an investigation, relevant organisations may proactively initiate safety action in order to reduce their safety risk. The ATSB has been advised of the following proactive safety action in response to this occurrence.

Department of Defence
As a result of this occurrence, the Department of Defence advised the ATSB that they are taking a number of safety actions. These include the following:

Compromised separation recovery training

The Department of Defence has released a Standing Instruction that mandates annual compromised separation recovery training for all air traffic controllers.

Controller briefing

All controllers will be briefed on the events and findings of the incident as an element of compromised separation recovery training.

Tower simulation capability

Tower simulation capability is being introduced to enhance compromised separation recovery training.

Additionally, simulation will be used to:

• compensate for low traffic levels and to facilitate controller attainment and retention of skills associated with processing complex traffic scenarios
  
• compensate for low traffic levels and to facilitate controller attainment and retention of skills associated with application of ATC priorities
  
• assess controller proficiency when live traffic levels are below that required to judge controllers’ abilities to process complex traffic scenarios
  
• provide controllers with regular exposure to compromised separation recovery scenarios, to improve decision making and ensure the associated actions become instinctive.
  
  

Airspace procedure briefings

The Edinburgh controllers will provide airspace procedure briefings to pilots who conduct airwork within and around Edinburgh airspace. The Airservices Australia Aeronautical Information Publication (AIP) En Route Supplement Australia (ERSA) entry for Edinburgh will be amended to include a section detailing the requirements for pilots of civil aircraft intending to conduct airwork within, or near, the Edinburgh control zone, to have airspace briefing.

 Hence (I guess) the ATSB quick wrap up of this investigation. However this incident had the potential for a lot more civilian fatalities than the sole occupant of the helo, if the Orion aircraft, minus tailfin, was unable to recover and spun out of control into outer Adelaide suburbia. 

Figure 2: Operating area of JXO, Edinburgh Control Zone and relative tracks


Source: Airservices Australia – annotated by the ATSB  

Maybe it is just me but a visual separation estimate of between 50-100 feet is just way too close for comfort - UFB!

P2 Comment: That said the ATSB Short Investigation team member(s) in collating and writing that report (in less than 4 months), did a sterling job with, 'by definition', very limited resources - Top job!


MTF..P2