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CASA GAAP HAZID Project

National Workshop Results December 2009

Version 1.0 Prepared for public release.

DEVELOPED BY

DEVELOPED FOR:

CASA GAAP HAZID National Project Team: CASA Project Manager: Peter John, Regional Manager Eastern Region CASA Aviation Safety Specialist: Michael White, CASA Aviation Safety Advisor CASA AARD (OAR) Representative: Graeme Rogers, Operations Manager, Office of Airspace Regulations Aerosafe Risk Management: Dr Richard Agnew, Senior Risk Advisor Johnathan Foster-Greenwood, Risk Advisor Observer to the CASA Workshops: Airservices Australia Matthew Buckham, Senior ATS Specialist, Safety and Environment

© COMMONWEALTH OF AUSTRALIA 2009 Published by Aerosafe Risk Management Address: Level 1, 40 Lord Street Botany, New South Wales, Australia Web: www.aerosafe.com.au Phone: +61 28336 3700 Facsimile: +61 28336 3799 This document has been developed by Aerosafe Risk Management Pty Ltd (Aerosafe) in response to a specific body of work that was commissioned and funded by CASA. The intellectual property expressed through the various structures, elements, models and methodology used to produce the report remain the property of Aerosafe Risk Management. While the publishers have taken every reasonable precaution and made reasonable efforts to ensure accuracy of material contained in this report, Aerosafe does not guarantee that this publication is without flaw of any kind. The publisher makes no warranties, express or implied, with respect to any of the material contained herein and therefore disclaims all liability and responsibility for any error, loss, damage or other consequence which may arise from relying on information in this publication.

December 2009

CASA GAAP HAZID Project National Workshop Results

Developed by: Developed for: Date: Version:

Aerosafe Risk Management Civil Aviation Safety Authority (CASA) December 2009 1.0

TABLE OF CONTENTS



Executive summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6

Part 1:

Introduction & background to HAZID Workshops. . . . . . . . . . . . . . 9 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10 Background . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10 Phase 3 terms of reference for CASA GAAP HAZID Workshops. . . . . . . . . . . . . . . . . . . 12 CASA GAAP HAZID Workshop aims. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12 Workshop assumptions & limitations. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13 Workshop & Survey Participants . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14 Phase 3: Methodology & approach. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14 Report structure. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15 Report outcome. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15

Part 2:

GAAP HAZID Workshop results . . . . . . . . . . . . . . . . . . . . . . . . . 17 GAAP HAZID Workshop results. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18 Evaluation of CASA safety interventions & activities. . . . . . . . . . . . . . . . . . . . . . . . . . . . 18 CASA GAAP on-line quiz . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19 CASA visit by Inspector . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20 CASA visit by Safety Advisor . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20 Director Aviation Safety e-mail message . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20 Director Aviation Safety letter to GAAP users. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21 Electronic sign boards at GAAP aerodromes. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21 Flight Safety Magazine articles July/August and October/ November . . . . . . . . . . . . . . . 22 GAAP Changes information booklet . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22 GAAP FAQs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23 Media Release - 15 July 09 on GAAP changes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23 Preventing Midair Collisions Kit. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24 Safety forums. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24 Website – GAAP dedicated section. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25 Synopsis of education activities as hazard mitigation. . . . . . . . . . . . . . . . . . . . . . . . . . . 25

Part 3:

Issues raised through industry consultation . . . . . . . . . . . . . . . . 27 Issues raised through industry consultation. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28 Current GAAP HAZID identification. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28 HAZARD 1: Management of approach & entry points into GAAP . . . . . . . . . . . . . . . . . . 28 HAZARD 2: Locating inbound reporting points . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29 HAZARD 3: Mixing the requirement for the circuit cap with arrivals and departures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29 HAZARD 4: GAAP aerodrome layout in respect to runway incursions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29 HAZARD 5: Inconsistent radio procedures and increased radio congestion. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29 Broader industry issues with GAAP operations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30 ISSUE 1: Pilot training, awareness and airmanship. . . . . . . . . . . . . . . . . . . . . . . . . . . . 30 ISSUE 2: ATC application of the GAAP changes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31 ISSUE 3: Consistency of GAAP standard operating procedures. . . . . . . . . . . . . . . . . . . 31 ISSUE 4: Commercial consideration for GAAP users . . . . . . . . . . . . . . . . . . . . . . . . . . . 31 ISSUE 5: Implementation of change . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31 Summation of workshop outcomes. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32

Part 4:

Options . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35 Industry discussion on the aeroplane cap in the circuit . . . . . . . . . . . . . . . . . . . . . . . . . 36 Industry input into additional HAZID mitigations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36 Development of options. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36 Option 1: No change to current circuit cap . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38 Option 2: Increase the circuit cap to eight. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39 Option 3: Increase circuit cap beyond eight on a case by case basis. . . . . . . . . . . . . . 40 Option 4: Unrestricted circuit cap - ATC discretion . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41

Appendix:

Appendix A: GAAP HAZID Workshops terms of reference . . . . . . . . . . . . . . . . . . . . . . . 43 Appendix B: CASA GAAP HAZID worksheets . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47 Appendix C: Invitation to attend – GAAP directions HAZID Workshop. . . . . . . . . . . . . . . 59 Appendix D: Glossary of Terms. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 63 Appendix E: References. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 66

EXECUTIVE SUMMARY

In late 2008, the Civil Aviation Safety Authority (CASA) commissioned two reviews into General Aviation Aerodrome Procedures (GAAP) aerodromes, one focusing on training, and the other on a broad range of issues including an assessment of risk at Archerfield, Bankstown, Camden, Jandakot, Moorabbin, and Parafield. In July 2009, the Director of Aviation Safety (DAS) implemented a series of changes at GAAP aerodromes to address the risks identified in these reports. These changes included the introduction of a cap in the number of aeroplanes permitted within the circuit area, a requirement for pilots to obtain a clearance from ATC prior to entering or crossing a runway, and longer term directions to Airservices Australia pertaining to the re-introduction of surface movement control and the use of Class D procedures The DAS made it clear that the cap on circuit numbers was an interim measure to be adopted until a broader education and awareness campaign was implemented, and when further mitigation strategies could be adopted. This report outlines the next phase in this safety evaluation process and follows on from the internal and external GAAP review and the implementation of safety interventions by the DAS to reduce the risk of mid-air collisions. A review team was established in late September 2009 to undertake a re-evaluation of the measures imposed in July 2009, and the effectiveness of the strategies adopted. A key focus of this review effort was to: • Conduct extensive industry consultation; • Seek feedback on the effectiveness of the safety interventions implemented, and • Seek information on any hazards that continue to exist at GAAP aerodromes. A concurrent evaluation of the safety intervention implemented via CASA’s GAAP safety educational campaign was undertaken as part of this process. The feedback provided by 179 industry participants indicated that there was an overwhelming view that these efforts had collectively increased the safety awareness of GAAP hazards and the associated GAAP changes. 98% of participants were aware of the GAAP changes and all had visibility of multiple education and communication tools used in this process. This evaluation indicated that CASA’s safety education campaign around GAAP was successful and well received by industry nationally. This focused and targeted GAAP hazard identification industry consultation process was undertaken utilising a HAZID Workshop methodology. Five key hazards and five broader industry issues were extracted as the key areas out of the information collated during the workshop. These hazards and issues are as follows: Hazards of Concern at GAAP Aerodromes

Broader Industry Issues with GAAP Operations

• Management of approach & entry points into GAAP zones

• Pilot training, situational awareness and airmanship

• Locating inbound reporting points

• Consistency in GAAP standard operating procedures

• Mixing the requirement for the circuit cap with arrivals and departures

• Commercial considerations for GAAP users

• GAAP aerodrome runway layout in respect to runway incursions Inconsistent radio procedures and increase in radio congestion

• ATC application of GAAP changes

• Implementation of change

In July 2009, the DAS announced that GAAP aerodromes will transition to Class D in 2010. Until this new arrangement is fully implemented a number of short term hazard mitigation strategies are required to keep the risk exposure to an acceptable level. The following options were derived by the National HAZID Workshop Facilitation Team following the national workshop series for consideration by the DAS. Each of these options has a set of associated hazard

6

mitigations that are required in order to provide the confidence and safety assurance that the mid-air collision hazard potential is being appropriately managed. The options are as follows: • Option 1: No change to current circuit cap • Option 2: Increase the circuit cap to eight. • Option 3: Increase circuit cap beyond eight on a case by case basis. • Option 4: Unrestricted circuit cap – ATC discretion This report presents the results of the industry consultation, the HAZID results and associated hazard mitigations for those hazards. The broader implementation and change issues need to be addressed as future transition to new arrangements are undertaken.

7

PART 1

Introduction & Background to HAZID Workshops

9

PART 1:

1.

INTRODUCTION & BACKGROUND TO HAZID WORKSHOPS

Introduction In July 2009, the Director of Aviation Safety (DAS) implemented a series of changes at GAAP aerodromes to address the risks identified in these reports. These changes included the introduction of a cap in the number of aeroplanes permitted within the circuit area, a requirement for pilots to obtain a clearance from ATC prior to entering or crossing a runway, and longer term directions to Airservices Australia pertaining to the re-introduction of surface movement control and the use of Class D procedures During October 2009, a series of GAAP HAZID Workshops and data collection activities were undertaken.

1.1

Background In 2008, CASA commissioned two reviews to examine aviation safety related issues GAAP aerodromes. A number of fatal and near fatal accidents and incidents had occurred in a relatively short period of time, following an extended period of relative accident-free aviation at GAAP aerodromes. Following presentation of information in the General Aviation Aerodrome Procedures (GAAP) Utility Review Report from the Ambidji Group1, CASA’s Director of Aviation Safety implemented a number of immediate safety interventions to reduce the risk profile. These safety mitigations included the introduction of a cap on the number of aeroplanes in the circuit area along with an extensive and comprehensive safety education campaign for GAAP users. The Director’s Directive came into effect on 21st July 2009 requiring: • “[a]n immediate limitation on the number of aeroplanes in the circuit for one runway, controlled by one Air Traffic Controller, to six. If two runways and two controllers are available then the total number of aeroplanes in the circuit would be limited to 12. An additional departure may be permitted at the discretion of the controller having given due consideration to all relevant safety factors. • An immediate requirement for all aeroplanes to obtain Air Traffic Control clearance to enter. Cross or taxi along a runway. • The provision (within 9 months) of aerodrome ATC daily for the hours of daylight without any reduction in the service currently provided during the hours of darkness.” 2 The rationale behind the selection of the aeroplane circuit cap took into account aeroplane performance and circuit capacity. The DAS was also conscious of the differences in the experience levels of both the ‘average pilot and Air Traffic Controller (ATC), staffing levels of ATC, changes in ATC duties and responsibilities at GAAP aerodromes, environmental conditions (such as physical/airspace layouts, meteorological), the hazards and emergent risks and activity indicators at the GAAP aerodromes. This safety intervention was implemented to provide a greater level of safety assurance. The DAS concurrently directed that a comprehensive safety education campaign for GAAP users be undertaken to ensure the implementation of these safety interventions were effectively communicated and executed. It was stated to industry that: ‘extensive qualitative and quantitative analysis had already been undertaken and CASA had [has] a duty as the regulator to take appropriate action to ensure safety standards were [are] at an acceptable level. The changes to procedures at the six GAAP aerodromes complement an extensive pilot education and awareness campaign that had already been initiated by CASA on key safety issues. This campaign is covering issues such as preventing mid-air collisions, gaps in pilot knowledge about GAAP procedures and education on situational awareness’. 3 The combination of the procedural and education interventions has had significant influence on raising safety awareness with the targeted focus on the reduction of the risk of mid-air collisions in the GAAP aerodrome zone and surrounding operating area.

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1



Ambidji Group Pty Ltd (Ambidji), in conjunction with Lloyd’s Register, 2009, Utility of General Aviation Aerodrome Procedures to Australian-administered Airspace (Report to CASA’s the Office of Airspace Regulation, June 2009.

2



CASA media release, ‘Improved safety at GAAP Aerodromes’, Ref: MR0966, July 2009.

3



GAAP Changes FAQ question., 4. Will the changes to procedures really have an impact on safety? (CASA, 2009).

These safety interventions were implemented at the six GAAP aerodromes nationally including Archerfield, Bankstown, Camden, Moorabbin, Parafield and Jandakot. With a cap on the number of aeroplanes in the circuit at these locations the risk of a mid-air collision was lowered due to the decreased density of aeroplanes in the GAAP airspace. The re-introduction of the requirement to obtain an air traffic control (ATC) clearance to enter, cross or taxi along any runway builds a stronger defence against runway incursions, which was also a major related safety issue at GAAP.

Figure 1. Location of GAAP aerodromes

An undertaking to revisit the interim safety interventions was given at the time of initial implementation. A formal national implementation team was established in late September 2009 to undertake this evaluation. A key focus of these review efforts was to conduct extensive industry consultation to seek feedback on the effectiveness of the safety interventions implemented, seek information on any hazards that continue to exist at GAAP aerodromes, and provide an opportunity for industry to voice their concerns and ideas for safety improvement at GAAP. The overall review of the safety issues at GAAP is being undertaken in four safety review project phases: Phase

Key Activity

Timelines

1

Formal Safety Assessment: on GAAP aerodromes in response to a spike in mid-air collisions. Both internal CASA review and external third party report including the GAAP Training report and the Ambidji Report etc

30 June 2009

2

Immediate safety interventions: implemented in response to intolerable risk at GAAP aerodromes. Safety interventions included comprehensive safety education campaign, cap on number of aeroplanes in circuit, requirement to obtain ATC clearance to cross taxiways, enhancements to ATC arrangements.

July – October 2009

3

Industry Consultation, Evaluation & Possible Adjustment to Safety Interventions: To review the effectiveness of safety interventions and undertake extensive industry consultation around current GAAP issues. National series of HAZID Workshops, issues identification and proposed solution development. The results of this phase of work would be used to inform whether any change to the interim measures would be made.

October 2009

4

Formal Safety Assessment on the transition of GAAP aerodromes to Class D arrangements as the long term strategy for risk reduction and standardisation.

Proposed 2010

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PART 1:

INTRODUCTION & BACKGROUND TO HAZID WORKSHOPS

The intent of the current activity (referred to as Phase 3) was to review the interim safety interventions and determine whether any additional interventions are required in order to effectively manage the risk until Class D is formally introduced. It is anticipated that the interim measures will be required for a 6-12 month period. Preliminary work is being undertaken by Airservices Australia and CASA’s Office of Airspace Regulation (OAR) in respect to Phase 4. Phase 3 is designed to be a stand alone phase focused on the management of this interim period. During the past three months, CASA has received formal and informal feedback on the safety intervention measures. Phase 3 was commissioned to provide the formal means of collating and considering industry information and determining whether the addition of local or national hazard mitigations could enable a controlled increase in the number of aeroplanes permitted in the circuit area without inducing additional risk. At the conclusion of Phase 3 a decision as to the status of the safety intervention measures will be made by the DAS. 1.2

Phase 3 Terms of Reference for CASA GAAP HAZID Workshops Consistent with the phasing of the safety review outlined in the introduction of this report, the DAS directed a review of the recently imposed directions relating to the maximum number of aeroplanes in the circuit at GAAP aerodromes . The focus of Phase 3 was to consult widely with industry nationally. Part of this undertaking to evaluate the effectiveness of these measures was to visit each of the GAAP aerodromes and conduct formal risk based (HAZID) workshops. The Terms of Reference included that the review would examine the current risks associated with operations at GAAP aerodromes following the introduction of controls through Directions issued to Airservices Australia and pilots. The review would undertake hazard identification (HAZID) workshops at GAAP aerodromes to establish whether the cap on aeroplanes in the circuit could be lifted consistent with the DAS’ advice to Airservices Australia and pilots that the current cap was viewed as a temporary measure pending further review. The workshops provided aviation industry participants, particularly those closely involved at and in GAAP aerodromes, with the opportunity of identifying the risk management procedures they may need to adopt to assist in reducing the risk of GAAP operations further than that already achieved through the implementation of the interim safety interventions. The methodology utilised to collect information is aligned with the Australian/New Zealand risk management process and was qualitative rather than quantative in nature. These workshops were co-facilitated by CASA and an external provider with expertise in aviation risk management. The Terms of Reference suggested that possible outcomes of the review could include, but may not be limited to: 1. A national analysis of the identified risks as gathered at a series of risk workshops conducted at Archerfield, Bankstown, Camden, Moorabbin, Jandakot and Parafield aerodromes. 2. A national analysis of the efficacy of the mitigations proposed at each location and a determination whether additional procedures or guidance material should be published; and 3. The provision of recommendations as to whether an alteration can be made to the current Directions to Airservices Australia. The HAZID Workshops were conducted at all GAAP aerodromes (Bankstown and Camden in a combined workshop) between 12-16 October 2009. The detailed Terms of Reference for the National HAZID Workshop facilitation team are outlined in Appendix A.

1.3

CASA GAAP HAZID Workshop aims The aims of the October 2009 workshops were to provide an opportunity for: • Industry to comment on the procedural changes at GAAP aerodromes that had been implemented as a result of the safety interventions,

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• Participants to comment on the effectiveness on CASA’s recent safety activities both procedural changes and education campaign, • GAAP stakeholders to identify any potential and actual hazards at their individual GAAP aerodromes along with any associated mitigations, and • Collection of comment on the circuit cap placed at GAAP aerodromes. The composite national Phase 3 project team who facilitated the CASA GAAP HAZID Workshops included: Appointment

Project Team Members

CASA Review Manager:

Peter John Regional Manager Eastern Region

CASA Aviation Safety Specialist:

Michael White CASA Aviation Safety Advisor

CASA AARD (OAR) Representative:

Graeme Rogers Operations Manager Office of Airspace Regulation

Aerosafe Risk Management

Dr Richard Agnew, CPRM

Workshop Facilitation:

Senior Risk Advisor, Aerosafe Risk Management

Aerosafe Risk Management Workshop Facilitation:

Johnathan Foster-Greenwood

Local representation:

Representatives from each of the CASA Regional Office attended, including regional representatives from Airservices Australia.

Risk Advisor, Aerosafe Risk Management

Observer to the CASA Workshops Airservices Representative:

Matt Buckham Senior ATS specialist, Safety and Environment

1.4

Workshop Assumptions & Limitations The HAZID Workshops were based upon a number of key assumptions and/or limitations: • That participants were representative of the GAAP aerodromes user mix and had a knowledge and understanding of the GAAP directive and resultant procedures, • The economic dimensions or impact of the safety interventions would be noted yet was not the key focus of this phase of work • That the results of previous safety reports and studies conducted in Phase 1 would not be further explored in Phase 3 • That the up-coming introduction of Class D airspace would be covered in Phase 4 of the safety project and would not be a key focus of workshop activities in Phase 3 • Assumption that those industry members who wished to formally contribute to this process were present at the HAZID Workshops or were active participants in the industry survey process, • That the information provided to the project team was true and correct; • The decision to transition GAAP to Class D remains an assumption and the results and outcomes of Phase 3 are required until this time;

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PART 1:

INTRODUCTION & BACKGROUND TO HAZID WORKSHOPS

• It is assumed that there is a broad acceptance by the Regulator and the industry that GAAP aerodromes by their very nature are not free of risk • An additional project team assumption is that if any change to the current arrangements are to be made, additional or compensating hazard mitigations are to be implemented to retain an acceptable level of safety • That the stakeholders involved in GAAP management and usage have the will and competency to effectively carry out the Regulators directives; and • Responses to questions and issues raised within the HAZID Workshops and/or the subsequent questionnaire were taken at ‘face value’. 1.5

Workshop & Survey Participants

Total

Other

Airport Operations

ATC

Manager/ Executive

Student

Instructor

Commercial Pilot

Bankstown/ Camden

18

15

5

5

0

8

1

0

6

58

Jandakot

16

6

3

0

0

5

1

2

4

37

Moorabbin

11

8

6

5

0

5

1

0

1

37

Parafield

12

3

1

1

0

2

2

1

3

25

5

4

3

0

0

6

1

0

2

22

62

36

18

11

0

26

6

3

16

179

Archerfield Total

1.6

CFI

Chief Pilot

The following table provides a breakdown of the participants who were involved in the national GAAP HAZID workshop:

Phase 3: Methodology & Approach The HAZID process adopted for the workshop was closely aligned to the Australian Standard for Risk Management (AS/NZS 4360:2004) and the Draft International Standard on Risk Management (ISO 31000: 2009) and involved the following activities:

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Activity

Details

Context Setting

Workshop participants were introduced to the scope and boundaries of Phase 3 safety review project. The background to details of the mid-air collision rate was presented and CASA safety interventions were listed and presented as the basis for the workshop.

Evaluation of safety interventions both procedural & education campaign

A formal survey was conducted that sought feedback as to 1) the level of awareness of each individual safety intervention 2) feedback on the perceived effectiveness of each safety intervention by the participant 3) perspective on the circuit cap, hazards and potential additional mitigations. It is to be noted that the same survey was issued to GAAP users electronically and the results of this activity were combined.

Activity

Details

Hazard identification exercise (HAZID)

Participants were guided through a hazard identification session which enabled the GAAP users at the workshop to identify hazards and provide detailed information on these hazards or concerns. The workshop participants were allocated to syndicate groups where the same exercise was duplicated. The syndicate results were then compiled into a collective response that is outlined in Appendix B. This was the main exercise for the workshop.

Development of local procedures at reporting points for entry into the circuit.

One of the key hazards that was identified was the risk of aeroplane activity at the inbound reporting points prior to gaining clearance to enter the circuit. This hazard was acknowledged as being pre-existing prior to the CASA directions. This specific hazard mitigation strategy was workshopped at each location. Further local development and agreement on these procedures were required following the workshop.

Open discussion

The workshop provided the opportunity for the National HAZID Workshop Facilitation team and workshop participants to engage in open discussion throughout the day on related and non-related topics.

Due to the timeframes involved between the HAZID Workshop and the completion of the HAZID Workshop Results report, it was not possible to produce accurate impact or implementation assessment for each of the options considered. Attendees were asked during the workshop to draw from their specialist experience operating at or in GAAP aerodromes, either at a particular location and/or more generally if their experience included one or more GAAP aerodromes. 1.7

Report Structure Given the context of Phase 3 of the GAAP safety review project, the objective of this report is to collate and present the results of the industry consultation activities to CASA. The information collected has been prepared for presentation in the following report structure: • Executive Summary • Part 1: Introduction & Background • Part 2: GAAP HAZID Workshop Results • Part 3: Issues raised through Industry Consultation • Part 4: Options • Supporting Appendices

1.8

Report Purpose This report has been prepared as a presentation of industry comments, evaluation, issues and solutions to the current GAAP safety project. The outcome of this report is not to provide recommendations to CASA but rather collate the information presented by industry and provide options for consideration. Part 4 of this report proposes a number of options the DAS may wish to consider in the interim period between now and the introduction of Class D requirements.

15

PART 2

GAAP HAZID Workshop Results

17

PART 2:

2.

GAAP HAZID WORKSHOP RESULTS

GAAP HAZID Workshop Results The CASA GAAP HAZID Workshop methodology outlined in Part 1 of this report was followed at each of the five GAAP HAZID Workshops. During the sessions participants discussed the areas to be considered within the time allocated at each of the GAAP aerodromes and participated in the formal activities. There were two other data input sources to the compilation of the GAAP HAZID Workshop results. They were the results of the online survey for GAAP users and secondly compilation of the issues received by CASA in the lead up to the HAZID Workshops both formally and informally. The online survey was designed to cover the same questions asked of the workshop participants in respect to the “evaluation of safety interventions both procedural & education campaign” activity. An abridged version of the HAZID activity was also included in the survey. Overall there were 110 industry participants involved in the national series of workshops and 84 industry participants who responded to the online survey. The level of participation is reflected in the following table: GAAP Aerodrome

Workshop Participation

Online Survey Participation

Archerfield

16

8

Bankstown / Camden

27

30

Jandakot

24

16

Moorabbin

27

19

Parafield

16

11

Subtotal

110

84

The survey was completed by a total of 179 participants from all six GAAP aerodromes. 95 participants completed the hardcopy survey and 84 completed the online survey. Fifteen people who attended the workshop did not complete the questionnaire. It should also be noted that 80% of participants operate a fixed wing aeroplane, the other 20% operate rotary wing aeroplanes. Appendix B documents each separate GAAP aerodrome’s workshop results which list the identified hazard and related mitigations according to each syndicate group’s discussion. In order to ensure the level of integrity, the language provided by the participants has been presented as it was submitted. These workshop results were circulated to participants for comment following the workshop and prior to the preparation of this report. 2.1

Evaluation of CASA Safety Interventions & Activities Participants at each of the CASA GAAP HAZID Workshops had the opportunity to comment in individual, collective (syndicate) and within group discussion level response to a questionnaire that aimed to solicit their awareness as well as the participants view of the effectiveness and other comments to fourteen CASA initiated safety activities following the introduction of the cap. Respondents overwhelmingly commented that they were aware of or had seen most, if not all, of the CASA safety activities related to GAAP education and awareness. The results from the questionnaire also show that the vast majority of respondents were senior participants either chief pilots, CFI and/or in senior management roles. This suggests that the questionnaire targeted the more senior and potentially the people most likely to assist in behavioural changes at the GAAP aerodromes. Positive and proactive training behavioural change will assist in reducing the likelihood of the exposure of GAAP participants to the identified risks and/or hazards.

18

The comments and rating of CASA’s safety activities were made by the more senior GAAP aerodrome users and will assist in the ongoing change management behaviour needed in the GAAP environment. These senior stakeholders also expressed their willingness to continue to promulgate and discuss and translate their thoughts and words into their own procedures, as well as those in their wider responsibility e.g. student pilots. The following educational activities were undertaken by CASA as a safety intervention strategy to reduce the risk of midair collisions at GAAP aerodromes. Listed in alphabetical order, these initiatives are as follows: • CASA GAAP on-line quiz • CASA visits by Inspectorate staff (past 3 months to discuss GAAP changes) • CASA visits by CASA Aviation Safety Advisors (past 3 months) • Director Aviation Safety e-mail message • Director Aviation Safety letter to GAAP users • Electronic sign boards at GAAP aerodromes • Flight Safety magazine article – July/August • Flight Safey magazine article – October/November • GAAP change information booklet • GAAP FAQs • Media release - 15 July 09 on GAAP Changes • Preventing midair collisions Kit • Safety forums • Website – GAAP dedicated section Those that completed the evaluation rating of the safety initiative were asked to rate the activity from 1-5. 1 being poor and 5 being excellent. A further expansion of this scale used to categorise feedback is as follows:



5

4

3

2

1

EXCELLENT

VERY GOOD

EFFECTIVE

LESS THAN EFFECTIVE

POOR

CASA GAAP on-line quiz This was a safety initiative introduced by CASA to aid those associated with GAAP aerodromes in understanding the key changes and regulations. Questions included such things as: who is primarily responsible for separation from other aeroplanes, landing clearance questions, how to react if there is frequency congestion, entering a GAAP control zone, overtaking slower aeroplanes etc. Most questionnaire respondents stated that they did not (by a factor of two) complete the CASA online GAAP quiz. In fact 122 of the 179 respondents did not complete the quiz. For those that did complete the online quiz, 66% rated this safety promotion activity as good or excellent. Effectiveness Answer

Percent

1

11.11%

2

0.00%

3

22.22%

4

44.44%

5

22.22%

20%

40%

60%

80%

67% of those that rated the effectiveness of this activity provided a very good or excellent rating.

100%

19

PART 2:



GAAP HAZID WORKSHOP RESULTS

CASA visit by Flying Operations Inspector Local CASA Inspectors visited organisations at GAAP aerodromes to carry out audits to ensure ‘best practice’ was being adopted. The two questions posed to GAAP stakeholders regarding wether their organisation was visited by a CASA Aviation Safety Advisor and/or an Inspector to discuss GAAP changes in the past three months was unfortunately “no” by a factor of two. Those questionnaire respondents that stated that they were visited stated that the visits were highly effective. Effectiveness Answer

Percent

1

6.25%

2

6.25%

3

37.50%

4

43.75%

5

6.25%

20%

40%

60%

80%

100%

50% of those that rated the effectiveness of this activity provided a very good or excellent rating.

CASA visit by Aviation Safety Advisor CASA Aviation Safety Advisors visited operators at and close to all GAAP aerodromes to discuss the changes implemented at GAAP aerodromes. This was a safety education initiative to help answer any questions that GAAP stakeholders and pilots may have had regarding GAAP procedures and the cap. Overall, the respondents indicated that the CASA visits were timely and engaging which led those that had the opportunity to discuss issue with the CASA representatives to be very complementary. Feedback also shows that possibly CASA liaison meetings and activities conducted at Moorabbin have been more effective than those activities and/or visits undertaken at other GAAP aerodromes. Effectiveness Answer

Percent

1

6.90%

2

13.79%

3

27.59%

4

27.59%

5

24.14%

20%

40%

60%

80%

100%

51% of those that rated the effectiveness of this activity provided a very good or excellent rating.

Director Aviation Safety e-mail message By far the majority of questionnaire respondents commented that they received the DAS’s message either by e-mail and/or read it on the CASA webpage. They commented that this was a very effective way of receiving the information. This comment is in slight variance to the comments received about the CASA website. The same respondents commented that they nearly all received the Director’s GAAP change letter to their respective organisations. In fact 79% or 141 of the 179 survey respondents received this e-mail message.

20

Effectiveness Answer

Percent

1

3.39%

2

8.47%

3

28.81%

4

50.85%

5

8.47%

20%

40%

60%

80%

100%

Over 59% of those that received the Director’s e-mail message rated this as very good to excellent.

Director Aviation Safety letter to GAAP users The DAS distributed a letter on the 3rd of August 2009 as a GAAP safety education initiative. It was sent to pilots to address the key GAAP issues and the identified misunderstandings. It also urged pilots to familiarise themselves with the information and other GAAP procedures found in the AIP, ERSA and NOTAMS. Effectiveness Answer

Percent

1

5.88%

2

0.00%

3

33.82%

4

45.59%

5

14.71%

20%

40%

60%

80%

100%

Over 60% of those that received the Director’s letter and rated the effectiveness of this communication vehicle rated this as very good or higher. Electronic Sign Boards at GAAP Aerodromes Two-thirds of the questionnaire respondents stated that they were aware of the mobile electronic signboards reminding pilots to obtain a clearance to enter/cross runways. The effectiveness rating of the electronic signboards was rated in the very high to excellent range. Questionnaire respondents from Bankstown GAAP aerodrome responded that they were far more aware of the electronic signage boards than those who responded from other GAAP aerodromes. Effectiveness Answer

Percent

1

10.20%

2

4.08%

3

18.37%

4

34.69%

5

32.65%

20%

40%

60%

80%

67% of those that rated the effectiveness of this activity provided a very good or excellent rating.

100%

21

PART 2:



GAAP HAZID WORKSHOP RESULTS

Flight Safety Magazine articles July/August and October/ November As part of CASA’s ongoing industry wide safety education efforts a safety magazine is distributed every two months. Two editions of the CASA Flight Safety Magazine ran special features on the GAAP changes with dedicated articles targeted at GAAP users. In respect to the specific articles on GAAP changes, the magazine articles presented information changes such as the cap on the number of aeroplanes permitted in the circuit and the requirement for all aeroplanes to obtain air traffic control clearance to enter, cross or taxi along any runway. Approximately 125 of the questionnaire respondents (70%) stated that they had read both the July/August and the September/October Flight Safety Magazine. This effectiveness rating was very high. The feedback on this aspect of CASA’s safety activities supports the idea that the targeted industry gain value out of receiving hardcopy material. Effectiveness (July/August) Answer

Percent

1

0.00%

2

4.00%

3

24.00%

4

52.00%

5

20.00%

20%

40%

60%

80%

100%

80%

100%

Effectiveness (October/November) Answer

Percent

1

0.00%

2

5.00%

3

25.00%

4

55.00%

5

15.00%

20%

40%

60%

For both editions of the Flight Safety Magazine that covered the GAAP changes, over 70% of respondents rated this safety activity as very good or excellent. GAAP Changes Information Booklet This booklet was produced for aviation safety education purposes. It served as advisory material only and it was stressed that it should not replace information contained in the Aeronautical Information Publication (AIP), En-route Supplement Australia (ERSA) and/or NOTAM. The information booklet identified the key changes in a simple and easy to follow format providing six facts about GAAP. The vast majority of questionnaire respondents or 150 of the 179 completed surveys commented that they also received the CASA GAAP changes information booklet and that this was very effective.

22

Effectiveness Answer

Percent

1

3.08%

2

3.08%

3

27.69%

4

47.69%

5

18.46%

20%

40%

60%

80%

100%

Over 66% of respondents rated the effectiveness of this booklet as very good or excellent.

GAAP FAQs A “GAAP changes frequently asked questions” section was uploaded onto the CASA website to help summarise the key concerns and questions that stakeholders were likely to ask. It included such questions as: ‘Why CASA made changes at the six GAAP aerodromes?’, ‘what steps have been taken to improve safety at GAAP aerodromes?’, ‘how was the cap on circuit movements set?’ etc. Approximately 84 of the 179 participants who responded to either the online survey or who contributed to the hard copy questionnaire said they were aware of this section on the CASA website. Effectiveness Answer

Percent

1

7.32%

2

12.20%

3

34.15%

4

43.90%

5

2.44%

20%

40%

60%

80%

100%

46% of those that rated the effectiveness of this activity provided a very good or excellent rating.

Media Release - 15 July 09 on GAAP Changes The media release provided information regarding the specifics of the DAS’s notice regarding the GAAP changes and the intent to issue a directive to pilots and Airservices on the changes. It communicated the effective date of these changes to be the 21st of July 2009. Approximately two-thirds of the questionnaire respondents commented that they were not aware of the Director’s initial media release related to the GAAP changes. However, those that did read the media release rated the effectiveness of the message as very high.

23

PART 2:

GAAP HAZID WORKSHOP RESULTS

Effectiveness Answer

Percent

1

9.38%

2

9.38%

3

21.88%

4

53.12%

5

6.25%

20%

40%

60%

80%

100%

59% of those that rated the effectiveness of this activity provided a very good or excellent rating. Preventing Midair Collisions Kit This special information kit was distributed to pilots of GAAP aerodromes. The kit contained several summary cards that offered sound advice on aviation safety issues at GAAP, the role of ATC at those aerodromes, effective lookout practices, radio procedures and maintaining situational awareness. Nearly all questionnaire respondents stated that they received the Preventing Midair Collision kits containing two colliding aeroplanes on the cover and containing a series of messages inside the kit. Questionnaire respondents rated the effectiveness of the kit from good to excellent. 18% of respondents indicated that this was not an effective tool Effectiveness Answer

Percent

1

5.66%

2

13.21%

3

22.64%

4

35.85%

5

22.64%

20%

40%

60%

80%

100%

Over 58% of those who answered this question provided an evaluation score as very good or excellent.

Safety forums Feedback from the workshops also highlighted the need for on-going dialogue between all stakeholders, and that these workshops were a very positive way in bringing together key stakeholders. Individual GAAP community representatives commented that they had initiated safety forums to assist their local GAAP aerodrome users in issues and/or concerns potentially affecting all stakeholders from their GAAP aerodrome area. An example of this initiative is the General Aviation Safety Forum undertaken at Parafield GAAP aerodrome. Other GAAP aerodromes have similar, at differing stages of maturity, forums to discuss safety issues. An outcome from discussions related to safety meetings was to promulgate more widely the minutes of such meeting to potentially target other GAAP pilots who may infrequently fly into and use these aerodromes. The use of the internet and hosting issues were discussed.

24

Website – GAAP dedicated section When questionnaire respondents were asked whether they were aware of the CASA website and the dedicated GAAP information section, the feedback was approximately 127 of the 179 respondents were aware and knew of this facility. Discussion at the CASA GAAP HAZID Workshops suggests that the lack of internet usage was possibly a reflection of the individuals choice of information gathering. Respondents suggested that the more technical minded pilots might prefer to receive information electronically and use the internet whereas potentially older generation pilots may prefer hardcopy mail-outs. The effectiveness rating on the awareness of the CASA website was consequently slightly lower, but still in the good range. Only about half of the questionnaire respondents commented that they were aware of the frequently asked questions (FAQ) facility, but those that did see it said that it was rated just below excellent. Effectiveness Answer

Percent

1

10.00%

2

6.00%

3

42.00%

4

30.00%

5

12.00%

20%

40%

60%

80%

100%

42% of those surveyed on this safety activity rated this as very good or excellent. 2.2

Synopsis of Education Activities as Hazard Mitigation Overall the survey results indicate a very high level of awareness around the GAAP changes. All questionnaire respondents commented that they were aware of the introduction of the procedural safety interventions including the cap on circuit numbers at GAAP aerodromes and the requirements to obtain a clearance to cross/enter runways at GAAP aerodromes. The survey results indicated that CASA’s dissemination and communication of these requirements was rated just below the highest effectiveness rating of excellent. The results demonstrate that CASA had reached their targeted audience informing them of the risk and the safety interventions extremely well. In summary, analysis of the survey responses indicate a 98% awareness of the CASA changes. The results also found that the educational and safety awareness activities were rated at very good to excellent over 42% in all cases. These results provide CASA with a very good indication that these activities were very effective in raising safety awareness of the GAAP changes. This evidence provided by industry shows that the awareness of the risks and hazards associated with GAAP aerodromes were understood. This heightened awareness through education is a good and effective risk mitigation.

25

PART 3

Issues Raised Through Industry Consultation

27

PART 3:

3.1

ISSUES RAISED THROUGH INDUSTRY CONSULTATION

Issues Raised Through Industry Consultation The national HAZID Workshop series was an opportunity for industry to identify, communicate and workshop a range of issues related to GAAP aerodromes. Part of the role of the national workshop facilitation team was to collate, structure and present industry’s issues to CASA. During the series of workshops, issues spanning strategic through to local issues were raised. To provide a suitable structure to issues resolution, the issues raised are presented in the following categories: • Current GAAP HAZID identification • Broader industry risk issues with GAAP operations • Implementation considerations with Phase 4 – introduction of Class D The raw workshop results presented in Appendix B are a combination of hazards, risks and issues. Part 3 of this report presents the key hazards that require attention and possible resolution in the period between now and the introduction of Class D.

3.2

Current GAAP HAZID Identification During the workshop, participants formed syndicate groups, nominating a scribe to record key discussion points that focused on their particular syndicates HAZID identification and associated mitigation. The top five hazards that were identified and relate to the current GAAP procedures include: 1. Management of approach & entry points into GAAP 2. Locating inbound reporting points 3. Mixing the requirement for the circuit cap with arrivals and departures 4. GAAP runway layout in respect to runway incursions 5. Inconsistent radio procedures and increase in radio congestion



HAZARD 1: Management of Approach & Entry Points into GAAP The hazards associated with aeroplanes holding at the inbound reporting points was highlighted as a key area of concern at all workshops. This hazard has always been in existence, yet with the changes the need to re-educate individual pilots in how to manage the situation if clearance to enter the GAAP control zone (CTR) is not given was discussed at length. The discussions at the five GAAP aerodrome workshops varied on their experiences related to entry into a GAAP aerodrome. At Bankstown for example, participants commented that at times it was difficult to get an inbound call due to frequency congestion and at times due to the quality of communications – also that 2RN was not easy to locate. At Parafield if entry to the GAAP zone was denied then pilots were forced into tight turns (potentially this issue may increase with better weather and longer daylight hours during summer, presenting an increase in aeroplane numbers). Archerfield’s participants commented that potential associated hazards included outbound traffic, transponders and visibility. The key hazards include: • Possible congestion at the inbound reporting points due to inability to gain a clearance to the GAAP CTR • Difficulties in entering into GAAP and the circuit • Radio congestion • Potential confusion by trainee pilots in the event that clearance is not given It was noted many times throughout the workshop and industry interaction, that this hazard was a key area of concern for most if not all participants. Mitigation strategies presented included; SIDs in the VMC for high performance aeroplanes, specified outbound heights to a nominated distance in En Route Supplement Australia (ERSA) for each aerodrome, education of airspace

28

constraints, landing lights on, improved knowledge of the airport, standardisation of operating procedures between operators, adding a Radar Information Service (RIS) specifically around inbound reporting points and GAAP aerodromes, increasing the numbers of ATC to aid the management of aeroplanes at these points, the standardisation of practices at inbound reporting points, increase the number of entry points nominated providing options to students in particular, give ATC greater control of aeroplanes within the zone, based upon the amount of movements occurring at the time. One GAAP aerodrome reported that there had never been a refusal on entry and when asked what the procedure would be if entry had been denied, the response was that there was no procedure. Some participants wanted ERSA to provide a ‘Plan B’ if entry was not provided with additional comment that ERSA could be made more user friendly adding colours, bullet points etc. Other potential solutions offered included the provision of new visual flight guides and/or exclusion zones and introduce inbound and outbound reporting points for aeroplanes (a formal reporting distance should be established).

HAZARD 2: Locating Inbound Reporting Points Linked to hazard 1, the hazards associated with the inability of inexperienced students or infrequent GAAP users to locate inbound reporting points was another great area of concern. This issue was raised at all workshops as the participants conducted their ‘what if’ scenarios. Pilots not making accurate position reports, and the location of inbound reporting points were seen at times problematic. Mitigation included flight school training, development of local procedures for inbound reporting and circuit re-entry and local level safety surveillance and monitoring. It was noted that the hazard mitigations for this specific hazard would need to be developed locally. The mitigations recommended by Industry are listed in the workshop summation of results in Appendix B. An example of these local hazard mitigations suggested at the Bankstown workshop was implementation of the M5/M7 interchange as a more prominent inbound reporting point that is easily identifiable.



HAZARD 3: Mixing the Requirement for the Circuit Cap with Arrivals and Departures Aeroplanes holding in the vicinity of inbound reporting points were seen as a potential hazard. It was noted that generally arriving and departing aeroplanes not engaged in circuit training activities have varying aeroplane performance and speeds. Mitigation solutions included; lat/long charts for pilots unfamiliar with the aerodrome, education for pilots to advise if they are ‘unfamiliar’ with the aerodrome, ATC use of vertical airspace as a separation, IFR arrivals being tracked direct rather than to approach points, approach points being recommended not mandatory. A difference in aeroplane performance was seen as a potential hazard that contributes to this issue (low speed vs high speed aeroplanes). Each GAAP aerodrome related their different ‘local’ rules with relation to aeroplane performance (e.g. Parafield a Citation approaches and departs at a slower speed than usual; Jandakot separates twin engine aeroplanes onto a separate runway, ie a slow speed circuit and a faster speed circuit). Helicopter activities (and potentially glider and/or balloons) generated discussion as potential hazards. Mitigation strategies included local rules and awareness and education to other aerodrome users.



HAZARD 4: GAAP Aerodrome Layout in Respect to Runway Incursions Each individual GAAP aerodrome is unique in its physical layout and related climatic conditions. It was observed that the legacy runway and associated taxi ways at Moorabbin GAAP aerodrome is arguably the most complex and takes users, including ATC, some time to understand the layout. This leads to increased workloads to both pilots and ATC given the introduction of request for clearance to cross taxiways and therefore the increased likelihood of error. Participants agreed that ongoing awareness, training and education were very important in mitigating the identified hazard. Strategies to manage and mitigate these hazards are required. This issue combined with the forecast of having all runways active was of concern and requires strategies to manage and mitigate these hazards.



HAZARD 5: Inconsistent Radio Procedures and Increased Radio Congestion All participants expressed radio procedures and experience as a potential hazard at GAAP. Radio call congestion,

29

PART 3:

ISSUES RAISED THROUGH INDUSTRY CONSULTATION

increased number of read-backs, lengthy nature of multiple radio calls, increased radio chatter within the zone, over complicated procedures and lack of conciseness were all seen as contributing factors. Participant mitigation included, education, flying students to visit the ATC towers, improve Aeronautical Information Package (AIP) phraseology, and an increased emphasis on airmanship and pilot situational awareness. This hazard was seen as significant particularly in respect to the increase in workload for student pilots. Comment was made on multiple occasions that owing to radio congestion, some students may be less inclined to seek assistance if they lose their situational awareness as a result of not wanting to further clutter the frequency. The inconsistency of what is being taught and the flow on effect of how this transpires into radio practices in and outside the GAAP zone was of concern. 3.3

Broader Industry Issues with GAAP Operations When examining the hazards during the industry workshops, it was apparent that many of the conditions that induce risk are broader industry risk issues and are not mutually exclusive to the GAAP changes implemented in July. In compiling the results of the workshop, it became apparent that there are a number of issues with training, procedures and practices that would warrant further systemic investigation. When reviewing the hazards specific to GAAP operations, there are strong linkages between these existing or induced hazards and the underlying systemic industry risk issues. In fact these issues can induce or increase the hazard potential. Although this activity captured these issues, they have not been fully assessed in light of the linkages, risks and solutions required to reduce these risk issues across this industry group. The broader issues captured in this process that may be worthy of further assessment include: 1. Pilot training, situational awareness and airmanship 2. ATC application of GAAP changes 3. Consistency in GAAP standard operating procedures 4. Commercial considerations for GAAP users 5. Implementation of change



ISSUE 1: Pilot training, awareness and airmanship Consistently GAAP HAZID participants identified and commented on the varying nature of pilot training, experience levels and situational awareness. Most of the discussion related to local GAAP aerodromes however some general observations can be made. Over the past five to ten years, there has been a shift in the profile of the size, type and scope of the flying schools now operating out of GAAP aerodromes. One of the key issues that this change has brought about is the increase in the percentage of the student population where English is a second language. It was recognised by this aspect of the flight training sector that potential communication issues were a recurring theme. In some cases, the issue of the ‘new’ generation of student pilots’ lack of foundational general aviation knowledge or familiarisation has the potential to challenge the traditional view of the underpinning awareness of what is ‘common or known’ knowledge. For example aeroplane recognition, mechanical knowledge, situational awareness of other aeroplanes, the importance of correcting incorrect practices. One example of this was in the case where a wide circuit was flown by student pilot A, student pilot B rather than adjust and fly the correct circuit from the individual aeroplane perspective would follow student pilot A and mirror the error. The GAAP aerodromes that had a higher proportion of English as second language noted that even though pilot students were now required by CASA regulations to be tested and competent in English, this competency often didn’t flow into a clear comprehension of ‘Australian’ English or aviation related terminology. This according to participants, increased student pilot workloads through not appropriately understanding ground school and flying instruction, communication confusion due to accents, speed of conversation, unclear responses back to instructors, other pilots or ATC requests. The participant consensus (as seen in the supporting Appendices) suggests that ongoing awareness, education and training needs to be undertaken along with a greater level of assessment of competency and conduct. Suggested

30

activities included: • Increase tower visits – greater understanding by both student and ATC, • Further develop cognitive skills within the ground school component – aeroplane identification, basic mechanics, • Commonality of training syllabuses, • Training facilities liaise more frequently. It is worth noting that General Aviation Safety Forums, such as conducted at Parafield are assisting in closer liaison. Participants commented that instructor quality may potentially be declining due to the airline ‘grab’. Participants saw the benefits of and noted that the Flight Training and Testing Office (FTTO) and Flight Training Examiners (FTE) are addressing this potential issue and that the regular CFI meeting that are being undertaken also address this concern.

ISSUE 2: ATC Application of the GAAP Changes All participants recognised the value of the services provided by ATC. Bankstown commented that there could be an increase in numbers of controllers and possibly an increase therefore in the tower’s operating hours. Parafield commented on the increased workload for controllers with regard to taxi calls and start-ups. The need for ATC training was also noted. Potentially in busy times, controllers are not going to actually count aeroplanes that they have under their control leading to a potential breaking of the required cap levels. Potential mitigation strategies commented by participants included; removal or relaxation of the formal ‘cap’, ATC to maintain their own internal discretionary ‘cap’ depending on experience or comfort, increase staffing and training for controllers, giving greater discretion to the individual controllers, and giving the controller the power to deactivate a strip. As a general comment, it was also noted that the circuit cap potentially in some conditions could or should be reduced further as two aeroplanes may be an individual controllers ‘cap’ due to weather conditions. Also it was noted that due to the increase in litigation, it is recognised that it is unlikely that an Air Traffic Controller will exceed the required cap by discretion owing to a fear of litigation in the event that an adverse event is experienced. Pilots and controllers reflected that they preferred directives.



ISSUE 3: Consistency of GAAP Standard Operating Procedures By far the most visible underlying issue raised was the lack of consistency in standard operating procedures for GAAP aerodromes and users. This issue was raised in respect to the GAAP changes and the more specific application of gaining agreement for standard operating procedures for inbound reporting point activities. Given the diverse and disparate nature of the operations that take place at GAAP aerodromes, and the individual commercial nature of each individual operating organisation, there is little or no cross over or sharing of practices or information. The potential exists for this to occur through the regional safety committees.



ISSUE 4: Commercial Consideration for GAAP Users Although outside of the scope of the safety assessment and HAZID activities, there was a high level of discussion on the commercial pressures that GAAP users are facing. Many of the businesses that operate out of GAAP are volume driven. Any change to the ability for these organisations to achieve their required volume may have significant financial impact. Lengthy discussion was had at three of the five workshops on this issue and there was a general acknowledgement that the HAZID and safety assessment needed to take place outside the commercial discussion. The National Workshop Facilitation team acknowledged that there were commercial implications associated with any change.



ISSUE 5: Implementation of Change During the activities, there was discussion around the activities required to implement change in regulation or procedure by the stakeholders at GAAP aerodromes. The level of change ranged from that associated with the ATC, Airport management, Instructor, students, periodical GAAP users and other stakeholders. In the absence of industry driven local safety committees, there is no formal structure by which this level fo change could be orchestrated. Although the message from CASA was clear and had a very high level of visibility, awareness itself will not ensure effective execution. An effective hazard mitigation would be to have an appropriate party develop a formal and structured change management process or plan to ensure compliance and adequacy of achievement.

31

PART 3:



ISSUES RAISED THROUGH INDUSTRY CONSULTATION

3.4 Summation of Workshop Outcomes The CASA GAAP HAZID Workshops achieved the stated aims of providing an avenue for industry consultation, allowing GAAP aerodrome users to discuss issues, identify their potential and actual hazards and the associated mitigation strategies, and comment freely on the introduction of a ‘cap’. Positive participant feedback was provided to facilitators at all of the venues. Participants stated that they found the opportunity to actively discuss and have documented their comments refreshing and that the workshop format and facilitation was appropriate. Analysis of the data and material gathered during the CASA GAAP HAZID Workshops and associated questionnaire revealed a range of hazards and issues. The participants proposed mitigation strategies from which arose several options for CASA’s consideration to review the current cap on the number of aeroplanes permitted to operate in the circuit area.

32

33

PART 4

Options

35

PART 4:

OPTIONS

4.

Options



Industry Discussion on the Aeroplane Cap in the Circuit When the initial circuit cap was introduced, it was met with a mixed response. Some were relieved that some boundaries had been introduced, while others were not convinced that a circuit cap would bring about the desired reduction of risk. To this end, during the workshop activity and related online GAAP user survey, further information pertaining to perceptions about the circuit cap were gathered. Participants were asked five additional questions that focused specifically on the introduction of the circuit cap. It is to be noted that participants were asked their opinion or perception rather than asked to participate in quantative analysis. The majority of participants who answered the questionnaire stated that they were aware of the introduction of the cap. However when asked to respond to ‘should there be a cap on the number of aeroplanes in the circuit?’ the responses were approximately equally divided. 104 of the 179 survey participants believed there should be some form of cap in the circuit. However, those participants who did want a cap would either like the cap to be increased or remain the same. Comment was made that any circuit cap should allow for inbound and outbound traffic to be determined by the ATC. The remaining 75 respondents to the survey, believed there should be no cap. Industry Input into Additional HAZID Mitigations As outlined in part 1 of this report, workshop participants had the opportunity to work towards the development of specific solutions that could be implemented to manage or mitigate the hazards identified. It was acknowledged that additional measures may be required if any adjustment was to be made to the current arrangements. Development of Options In reviewing the results of the national HAZID Workshops and associated supporting activities and documentation, the National HAZID project team was asked to prepare options that may be considered in evaluating the next steps in respect to GAAP aerodromes. In developing these options, the National HAZID Project team sought a level of assurance that the heightened safety state would remain in the transition period between now and the introduction of Class D. It was noted that Airservices Australia had commenced work on a safety case and HAZID specific to Class D and there would be more work and consultation with industry scheduled in coming months.

36

The team proposed four options for consideration:

OPTION 1 Maintain the current circuit cap of six aeroplanes with arrivals and departures to be managed by Air Traffic Control.

OPTION 2 Increase the circuit cap to eight aeroplanes with arrivals and departures to be managed by Air Traffic Control.

OPTION 3 Increase the circuit cap at specific GAAP aerodromes beyond the directed limitation on a case by case basis. This option is predicated on the implementation of the following risk mitigations and an assessment of efficacy of: a. Development of a local traffic management plan by Airservices Australia, including the development of local sequences operating procedures for the management of aeroplanes at inbound reporting points; b. Development of individual training implementation plans by GAAP operators to ensure adequate execution; and review of these implementation plans by Airservices Australia as a supporting activity of the enhanced local traffic management plan. c. CASA to review Airservices Australias GAAP aerodrome risk management plans.

OPTION 4 Remove the current circuit cap with all aeroplane movements to be managed by ATC. If this option is adopted it should require the development of a formal safety assurance regime by Airservices Australia for the management of traffic at GAAP aerodromes.

37

PART 4:



OPTIONS

Option 1:

No change to current circuit cap

Maintain the current circuit cap of six aeroplanes with arrivals and departures to be managed by Air Traffic Control.

Rationale behind this Option The rationale behind maintaining the recently imposed cap of six aeroplanes per circuit is based upon the success of this safety intervention strategy on reducing the aeroplane activity in the circuit and thus reducing mid-air collision exposure. The issue of experience and work load levels of Air Traffic Control varied from place to place. Retaining the cap would provide a consistent platform for all GAAP aerodromes. It was recognised that some controllers are capable of safely managing more than six aeroplanes within a circuit while concurrently managing aeroplanes in the greater GAAP zone. It is also recognised that in some circumstances a controller may be only able to safely manage less than six aeroplanes in the GAAP circuit. Situations such as hazardous metrological conditions, low visibility conditions, assistance rendered to a pilot experiencing or requesting such assistance, and aeroplane emergencies may require a limit to the number of aeroplanes operating in a circuit area. This option differs from the current situation in that it allows for unrestricted arrivals and departures. This will remove a level of perceived complication and allow the aeroplane circuit cap to be focused around those that are conducting circuit training. The other element to the rationale of this option is, given the expected short term period between now and the transition to Class D airspace, continuation with the current arrangement would alleviate the need for further change. Given the disparate nature of GAAP users, any additional change will require communication and education. This option would allow for the current procedures to be bedded down further. The development and safe execution of localised aeroplane sequencing and/or operating procedures for inbound reporting aeroplanes should be a pre-condition for each of the four options. Expected outcome from the implementation of Option 1 (benefit) The major benefit of capping the GAAP circuit to six aeroplanes allows for continued better flight management. Both pilots and controllers utilising the cap should be able to manage their activities such that there is now a greater level of assurance and expectation of the location of other circuit traffic within the GAAP zone leading to a reduction in hazard exposure. Permitting arrivals and departures to be managed by ATC, separate to the circuit cap, will reduce the potential for delays for airways clearance at inbound reporting points. Criteria for evaluating effectiveness of Option 1 As part of CASA’s safety assurance regime, the following criteria for evaluating whether Option 1 is effective and delivers on the planned outcome is as follows: • Confirmation that the circuit cap is being followed • Close monitoring of any incident, occurrences or near misses that result from the existing hazards identified with the GAAP arrangements • Assurance around the implementation of HAZID mitigations nominated during the national workshop series. Since the introduction of the cap in July 2009, feedback to CASA includes how many occurrences of exceeding the cap within the GAAP zone. Assurance reporting from Airservices Australia will also assist CASA in determining whether more awareness and education activities are required. Pilot feedback through individual reporting, CFI and Chief Pilot reports as well as FTTO and CASA Aviation Safety Advisor feedback will provide a level of safety assurance.

38



Option 2: Increase the circuit cap to eight. Increase the circuit cap to eight aeroplanes with arrivals and departures to be managed by Air Traffic Control.

Rationale behind the Option Feedback from the CASA GAAP HAZID Workshops combined with comments made by various controllers during the GAAP aerodrome visits, confirmed that most experienced controllers base their safety criteria at the management of eight aeroplanes within the GAAP circuit at any one time. The safe management of eight aeroplanes within the GAAP circuit could be predicated on the safe execution of localised aeroplane sequencing. The risk of mid-air collision at GAAP aerodrome and the associated hazards are known and understood by industry. As part of CASA’s continued oversight of this issue, dedicated industry consultation to assess the effectiveness of the education campaign that was enacted as part of this project. The results of this industry engagement indicate that there is now a heighted awareness of the safety risks and hazards at GAAP aerodromes. This greater level of awareness has caused operators at GAAP aerodromes to examine this issue closely. The national HAZID workshops provided a further platform for these issues to be identified, explored and addressed. Based on the increased awareness of industry along with the extensive education and informational campaign on GAAP changes, an increase of the cap to eight aeroplanes in the circuit is a viable option. Airservices Australia and all Operators at a location are to implement their own risk management strategies for this option as part of their ongoing safety management system The development and safe execution of localised aeroplane sequencing and/or operating procedures for inbound reporting aeroplanes should be a pre-condition for each of the four options. Expected outcome from the Implementation of Option 2 (benefit) This option will provide GAAP users with an increased circuit capability. The implementation of this change will provide the opportunity to reinforce the education activities and further address the management and reduction of the identified hazards. Permitting arrivals and departures to be managed by ATC, separate to the circuit cap, will reduce the potential for delays for airway clearance at inbound reporting points. Criteria for evaluating effectiveness of Option 2 As part of CASA’ safety assurance regime, the following criteria for evaluating whether Option 2 is effective and delivers on the planned outcome is as follows: • Confirmation that the cap is being followed • Continued monitoring of any incident, occurrence or near miss that results from the existing hazards identified with the GAAP arrangements • Evaluation of the implementation of these changes jointly by Airservices Australia, CASA and GAAP operators.

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PART 4:



OPTIONS

Option 3: Increase circuit cap beyond eight on a case by case basis. This option is predicated on the implementation of the following risk mitigations and an assessment of efficacy of: a. Development of a local traffic management plan by Airservices Australia, including the development of local sequences operating procedures for the management of aeroplanes at inbound reporting points; b. Development of individual training implementation plans by GAAP operators to ensure adequate execution; and review of these implementation plans by Airservices Australia as a supporting activity of the enhanced local traffic management plan. c. CASA to review Airservices Australias GAAP aerodrome risk management plans.

Rationale behind the Option The circuit cap could be increased beyond eight on a case by case basis if appropriate additional risk mitigators are identified, agreed and implemented. Given that this option would extend beyond the existing predetermined state a formal level of safety assurance is required. This formal assurance regime would be gained through the above recommended activities. The development and safe execution of localised aeroplane sequencing and/or operating procedures for inbound reporting aeroplanes should be a pre-condition for each of the four options. Expected outcome from the Implementation of Option 3 (benefit) One benefit in increasing the number of capped aeroplane movements within the circuit area is the potential reduction in the refusal of an inbound aeroplane into the GAAP zone. It was recognised that by refusing a pilot entry into the GAAP zone could result in him/her holding in the vicinity of the inbound reporting point. By requiring the development and successful implementation of localised aeroplane sequencing and /or operating procedures at approach and inbound reporting points, an additional layer of hazard mitigation will be achieved. Lifting the cap from six to eight aeroplanes would be an incremental adjustment that is compensated by the additional GAAP flight sequences and local procedures. The increase from six to eight aeroplanes recognises that the education and awareness strategies thus far have been effective. Given the effectiveness of the education campaign and input from the workshops, it was considered that ATC traffic management should be permitted in assessing arrivals and departures in the GAAP zone. Criteria for evaluating effectiveness of Option 3 As part of CASA’s safety assurance regime, the following criteria for evaluating whether Option 3 is effective and delivers on the planned outcome is as follows: • Implement a formal safety assurance program for this option • Close monitoring of any incident, occurrences or near misses that result from the existing hazards identified with the GAAP arrangements • Assurance around the implementation of HAZID mitigations nominated during the national workshop series. • The effectiveness of any associated education and change awareness campaign The utilisation of formal CASA safety assurance mechanisms in relation to ATC practices can demonstrate effective ongoing safety monitoring. Part of the continued safety assurance regime is the ongoing awareness and education program provided by CASA to GAAP aerodrome users. A significant and integral component of the safety assurance plan is the ongoing education provided by CASA’s Aviation Safety Advisors. Safety forms, visits, targeted awareness and training safety related material and feedback from users also adds to the safety assurance regime. All GAAP aerodrome users should be monitoring and reporting formally to the ATSB.

40

Option 4: Unrestricted circuit cap – ATC discretion Remove the current circuit cap with all aeroplane movements to be managed by ATC. If this option is adopted it should require the development of a formal safety assurance regime by Airservices Australia for the management of traffic at GAAP aerodromes.

Rationale behind the Option The major rationale behind the removal of a ‘cap’ imposed at GAAP aerodromes is that all ATC are experienced and trained to exercise their discretion (judgement). Airservices Australia has a dedicated and professional ATC staff that are well trained to preform their function. Less experienced controllers are rostered with controllers who have greater experience and strict roster scheduling also assists in management of fatigue. Local controllers have extensive understanding and knowledge of their unique airspace, geography and weather conditions as well as many of the existing aeroplane operational activities. The development and safe execution of localised aeroplane sequencing and/or operating procedures for inbound reporting aeroplanes should be a pre-condition for each of the four options. Expected outcome from implementation of Option 4 (benefit) By granting greater ATC discretion will allow CASA will return to an active monitoring role. Criteria for evaluating effectiveness of Option 4 As part of CASA’s safety assurance regime, the following criteria for evaluating whether Option 4 is effective and delivers on the planned outcome is as follows: • Confidence in Airservices approach to execution • Assurance around Airservices approach to monitoring the hazards and any change in risk profile • Visibility of the individual GAAP aerodrome performance in this area, along with the opportunity for visibility of the national cumulative result Giving ATC discretion on the number of aeroplanes that an individual controller can manage at any one time within the GAAP aerodrome environment would have to be supported by an auditable and transparent safety assurance process as part of Airservices Australia’s safety management system. The above activities should give a high level of oversight and transparency of controller’s performance and GAAP aerodrome management and thus a greater level of safety assurance.

41

PART 1 APPENDIX A

Introduction GAAP HAZID&Workshops Background Terms to HAZID of Reference Workshops

43

APPENDIX A:

Purpose The Director of Aviation Safety has directed a review of the recently imposed Directions relating to the maximum number of aeroplanes in the circuit at GAAP aerodromes. This review will examine the current risks associated with operations at GAAP aerodromes following the introduction of controls through Directions issued to Airservices Australia and pilots. The purpose of the HAZID Workshops is to establish whether the cap on aeroplanes in the circuit could be lifted and is in line with the Director’s advice to Airservices Australia and pilots that the current cap was viewed as a temporary measure pending further review. This process provides the mechanism to enable the foreshadowed review. CASA has implemented a range of initiatives designed to improve the safety of GAAP operations and to manage the risks identified in the Utility of GAAP Review (known as the Ambidji Report). The workshops will provide industry with the opportunity of identifying the risk management procedures they may need to adopt to assist in reducing the risk of GAAP operations to as low as is reasonably practicable. The methodology utilised will be a series of hazard identification (HAZID) workshops at each GAAP aerodrome location (noting that Camden and Bankstown will be a combined HAZID Workshop). These workshops will be co-facilitated by CASA and an external provider with expertise in aviation risk management. Review outcomes Outcomes of this review will be: 1. A national analysis of the identified risks as gathered at a series of risk workshops conducted at Jandakot, Parafield, Moorabbin, Camden, Bankstown and Archerfield aerodromes. 2. An national analysis of the efficacy of the mitigators proposed at each location and a determination whether additional procedures or guidance material should be published; and 3. The provision of recommendations as to whether an alteration can be made to the current Directions to Airservices Australia. Scope The aim is for workshops to be conducted at all GAAP aerodromes (Jandakot, Parafield, Moorabbin, Camden/ Bankstown [combined workshop] and Archerfield).

44

45

APPENDIX B

CASA GAAP HAZID Worksheets for Archerfield, Bankstown/Camden, Jandakot, Moorabbin and Parafield

47

APPENDIX B:

CASA GAAP HAZID Worksheet Location Name: Archerfield SER 1

HAZARD/ ISSUE

PROPOSED SOLUTION / MITIGATOR

Entry to GAAP zone.

- SID’s in the VMC for high performance aeroplanes

- Outbound traffic - Transponders

- Specified outbound heights to a nominated distance in ERSA for each aerodrome

- Visibility

- Education of airspace constraints – landing lights on - Improve knowledge of the airport - Standard operating procedures between operators - (adding a RAS specifically around inbound reporting points and GAAP aerodromes)

2

3

VFR ‘second class citizens’

- Increased resources

- Limited traffic alert reporting from Brisbane radar

- Workshops/ education for ASA and pilots

Location of inbound reporting points

- Introduction of Class D – change of inbound points e.g. Target (hard to see) – IKEA (easy!) - Lat/ Long on charts for pilots that are unfamiliar with the aerodrome - Education for pilots to advise if they are ‘unfamiliar’ with the aerodrome

4

Helicopter inbound flight paths

- Lower altitude entry rather than descending through (E.g. Choppers North at YSBK)

5

UNIVATT (University of Qld to Mt Gravatt) lane North YBAF

- Develop educational material

- No educational material on how to fly this lane 6

Non-English speaking backgrounds (students to tower)

- Education of instructors/ students (including tower visits)

- English standards/ assessments from overseas are poor – not to aviation standard

- Different Caps for circuits involving non-English backgrounds

- Pressure from ‘airlines’ and ‘contract owners’ to push students through in minimum time

- Flexibility back to the controllers to set their own limits

- Aggression from ATC

- Develop awareness and cognitive visual skills (visual and aural)- teaching students - Pre-flight ground training (scenario training on the ground- record live radio communication in the cockpit and play it back to those learning)

7

Capping inbound traffic (Holding at inbound reporting point)

- Education for ‘plan B’ – ATC and pilots

- Major hazard if held at inbound points (not following procedures from the start)

- Communication/ advice from tower to all operators

- Standard procedures - ERSA – provides ‘plan B’ if entry is not provided - ERSA could be improved – colours, bullet points etc. - New visual flight guides - Exclusion zone/area put on inbound reporting point for outbound aeroplanes (a formal distance should be established)

48

CASA GAAP HAZID Worksheet Location Name: Archerfield SER 8

HAZARD/ ISSUE

PROPOSED SOLUTION / MITIGATOR

Confusion about outbound/ inbound flight paths

- Requirement to fly directly overhead - Improved education material - Lights/ tracking strobes outbound - Knowledge of procedures (reading documentation)

9

10

Joining the circuit – descent on inbound vertical separation

- Education to pilots and training providers

Heads in the cockpit (reliance on GPS for tracking)

- Education

- Standard procedures (e.g. 3ml – reduce speed and begin decent to join the circuit)

- CASA DVD’s about situational awareness and scanning techniques - Keeping a good lookout/ airmanship - Glass cockpit technology can compromise lookout

11

Workforce size – ASA - Increased costs to operators. Will Government pass this onto users?

12

Sun up sun down ATC’s

- Limited capacity and experience – splitting of frequencies, increased workload (spread too thin) - Minimum of 5-6 extra controllers - ATC’s with smaller role/ responsibilities therefore faster training time - Possible fixed wing circuit training times (e.g. from 7am until 5pm) - Needs to be appropriate for aerodrome

13

Reed-backs too lengthy

- Re-education of reed-back requirements and situational awareness/ airmanship

14

Confirming identification of other traffic (awareness)

- Pilots need to report if they lose sight - Standard operating procedures between flying schools - Scenario training required to improve level of awareness (e.g. ground training) - Maintain formal meeting between flying schools and ATC - Distributing information through a common website for flying schools and other operators

15

Difference between A/c (speed)

- Commonality of SOP’s - Education and communication

49

APPENDIX B:

CASA GAAP HAZID Worksheet

Location Name: Bankstown/ Camden SER 1

HAZARD/ ISSUE

PROPOSED SOLUTION / MITIGATOR

Congestion at approach points

- IFR arrivals should be tracked direct rather than approach points

- Holding procedure not standardised - Holding A/c due to the Cap (too many)

- Approach points should be recommended not mandatory - Lowering the upper level of R555 (give a recommended inbound point –Holsworthy) - Another recommended inbound entry point at Westmead Hospital

2

ATC staffing not enough

- Controller should decide the number in the circuit (No Cap!) - Increase tower hours - Increase ATC staffing

3

High levels of traffic - Not enough aerodromes

- Re-opening of Schofields and Hoxton Park to reduce the pressure on Bankstown - Remove unnecessary clearance requirement to cross un-lit runways at night - Disciplined but minimum read back requirements

4

Entry to GAAP

- More entry points required

- Hard to get inbound call due to frequency congestion and quality of communication

- More entry points required related to A/c speed

- 2RN is not easy to locate

- Education and training re: joining the circuit (traffic sighted calls)

- Low time pilots

- Holding procedure needs to standardised - Increase ATC staffing numbers

5

Joining the Circuit: - A/c numbers are not necessary related to collision risk

- Pilot education to be able to cope with different scenarios

- Mixed performance A/c - Lack of experience - Converging traffic on downwind R29

6

Types of A/c: - High speed vs Low speed - Pilot understanding of A/c performance

50

- Segregate high and low performance aeroplanes.

CASA GAAP HAZID Worksheet

Location Name: Bankstown/ Camden SER

HAZARD/ ISSUE 7

PROPOSED SOLUTION / MITIGATOR

IFR Training: - Glider ops (Camden) - Lowest safe act conflicts with GAAP procedure - Restricted VFR with inbound IFR

8

Radio procedures and communications: - Overcomplicated procedures

- Pilots often request clearance at late notice, therefore introduce early reporting.

- Not concise

- Flying students to visit ATC towers

- English as a second language (overseas students)

9

Reporting points- (see notes)

- Use 10 mile radial entry rather than fixed reporting points - Introduce another reporting point (at the moment there are only two)

Comments: It was a shared point of view that their was no problem until the Cap was introduced (Bankstown GAAP is historically safe) And that ATC should manage the circuit numbers based on the following: 1. ATC staff level 2. the traffic mix (i.e. different aeroplane types and pilot experience levels) 3. Airspace 4. Weather 5. increased inbound reporting points There is no procedure to follow when clearance is not available (in-bound), their needs to be a standard prescribed procedure.

51

APPENDIX B:

CASA GAAP HAZID Worksheet Location Name: Jandakot SER

HAZARD/ ISSUE

PROPOSED SOLUTION / MITIGATOR

1

Significant increased risk at the entry point (this is seen as the main hazard)

- Revert back to ATC discretion on the number of aeroplanes in the circuit

2

No publicised procedure for entry at 6 south

- Alignment of procedure between operators at Jandakot - teach and educate students

3

ATC interpretation

- CASA clarification

4

Standard Circuit pattern and aeroplane recognition/ identification

- Consistent size and shape of the circuit - Increase the number of ATC’s and or change their work load - Rework roles and responsibilities (ATC assistant) - Requesting circuits via telephone

5

Different speeds of A/c in the circuit

- Put the twins (high performance a/c) on separate runway (segregate circuits based on aeroplane performance)- segregate high and low performance aeroplanes.

6

GAAP entry (safe free flowing entry)

- If the tower can have control of aeroplanes in the zone, based on the amount of movements occurring at the time

- Solo students 7

Tower outside 3 ml boundary has no authority

- Potential to extend that boundary to encompass entry points (this would give the controllers more time) - No clearance available procedure - Have competent controllers (they would have discretion as to how many are allowed in the circuit)

8

Radio call congestion

- Can the content be reduced - Education

9

Joining the circuit (06 L)

- VPG available on the website and updated - Pilot education to be able to cope with different scenarios

10

Joining Runway 12 (being unfamiliar with it)

- Education to be familiar with Runway 12 (DVD education material, how to deal with slow aeroplanes following a fast aeroplane on arrival for all runways, judging and maintaining spacing) - Circuit size - Reduce congestion (ATC discretion)

52

CASA GAAP HAZID Worksheet Location Name: Jandakot SER 11

HAZARD/ ISSUE

PROPOSED SOLUTION / MITIGATOR

Poor operating discipline (both in the tower and the pilot)

- Discipline through education - Writing procedures - Flying and ATC supervision - New instructor education and orientation

12

Inadequate briefing time for IFR student pilots on departures (non-standard IFR briefing procedures at Jandakot)

- Introduction of SID - Change radar SID to procedural SID - Earlier delivery of the clearance - Departure instruction pre-taxi

Additional comments and issues: - Jandakot is yet to see the full impact of the limitations to the circuit - If the boundary to entry points is extended this may have a noise impact - The introduction of Class D will add extra components

53

APPENDIX B:

CASA GAAP HAZID Worksheet Location Name: Moorabbin SER 1

2

HAZARD/ ISSUE

PROPOSED SOLUTION / MITIGATOR

Frequency overloading and congestion (students have to filter what is important and what isn’t)

- Educating pilots in the correct read backs

Increased ATC workload (coordination) due to the cap

- ATC to have discretion to allow unrestricted departures and arrivals as they see fit

- Reduce the listening out

- ATC to have power to de-activate a runway 3

Circuit sizes

- Need for a cap (don’t include arrival and departures and can set a higher cap for circuit only traffic)

4

Cockpit workload

- Reduce the amount of radio chatter

5

Circuit operation (different speed profiles and aeroplane types) – this can add to the problems for the controller and the pilot

- Have standard speeds in a circuit

6

Aerodrome layout (potential to misidentify your runway)

- Education and awareness

7

Having all runways active

- April 2010 introduction of Class D airspace

8

Traffic at entry and exit points

- Better segregation of routes - Vertical and lateral separation

9

Approach point issues (misconception that pilots need to depart via an approach point) (ie. GMH not prominent)

- Have different altitudes based on type of aeroplane - Procedure for departing Moorabbin (ie a SID for VFR) - Students are to make appropriate decisions (ie proceeding to another entry point) - Education on procedures when clearance not available (in-bound), their needs to be a standard prescribed procedure. - Clearance should be sort before the entry point

10

Aeroplanes not making an accurate position report to where they are

- Education

11

Joining the circuit and circuit sizes

- Standardise circuit joining instructions

12

Private pilot lack of awareness and discipline to plan

- Establish a help line - Flight review every 2 years

54

13

Communication (language barriers, ATC’s struggle to understand what the pilot has said)

- Education and English testing standards

14

Transition from IFR to VFR

- Melbourne centre to have more control to position aeroplanes (April 2010)

15

Unfamiliar with other GAAP operating aeroplanes

- Education and abinitio training

CASA GAAP HAZID Worksheet Location Name: Moorabbin SER

HAZARD/ ISSUE

PROPOSED SOLUTION / MITIGATOR

16

AIP format and language (Non user friendly or intuitive)

- Reformat

17

GAAP procedures vary between aerodromes

- Procedures should be standardised to the maximum extent

18

Poor aeroplane recognition (in relation to type and performance)

- Education charts - Educate students to practice better lookout (see and avoid and blind spot awareness)

Comments: If there is a cap on movement rate it may result in transferring traffic – this is simply moving the hazard to other airfields

55

APPENDIX B:

CASA GAAP HAZID Worksheet Location Name: Parafield SER 1

HAZARD/ ISSUE

PROPOSED SOLUTION / MITIGATOR

Entry to the GAAP zone – If pilots are not given clearance they are forced into tight curves (where do aeroplanes go?)

- ATC has been told to give priority to inbound aeroplanes (others in circuit might be told to make full stop to make a slot). It should be publicised that ATC give priority inbound

- Problem might get worse with better weather in the summer, as there will be an increase in flights - Business hazard – increased cost of training when circuit training flight is lost (The circuit cap of 6 aeroplanes on each runway is considered to be ok for Parafield however it should not include arriving/ departing aeroplanes in the overall cap)

- FTA (Flight Training Adelaide) and UniSA (University of South Australia) has an established procedure to go to St Kilda and fly around and back to OH (over head?) if no clearance given. Pilots are to maintain 1500’ from the river mouth - Suggest standard procedure for all as above. - Similar procedure needed if held at East approach point re: rejoining the outbound track and try again to approach point - Changes on 19/11 might help with procedures if held outside the zone

2

ATC Workload issue: ATC has to keep count of aeroplanes in the circuit

- Remove formal cap (ATC can maintain their own internal cap)

3

ATC increased workload for taxi calls and start up clearance (Note: this improves situational awareness for everyone; Flying school, ATC like this change)

- Increase ATC staff

Note: this may get worse in Class D 4

ATC are currently training operators with the cap in place. If it is removed then ATC’s will not be trained with high volume ops

- If/when cap is removed ATC might need more training

5

Different performance aeroplanes – If there is a cap, ATC mix high and low performance aeroplanes on same runway (rather than keeping them segregated) to keep within cap limits

- Remove cap and give discretion back to ATC

6

Radio procedures and experience

- Look at reducing required transmissions in the zone (Note: example of airfield with 10 aeroplanes in circuit with reduced Radio Telephony (R/T) procedures)

- (Too many radio calls in zone)

- Improve AIP phraseology (specific section for GAAP) - Educational awareness for standard phraseology 7

Non standard circuits (ie students flying wider and wider circuits)

- This was addressed through Aviation Safety Forum and seems to be mostly fixed - More consultation with the flying schools to achieve a standardised circuit

8

9

56

English as a second language students taking time to understand radio transmissions and respond promptly

- Flying schools to increase training/ practice offline

Cap has drawn circuit operations out during the day so the airport operator has less time to do runway maintenance

- Remove cap and give discretion to ATC

- ATC to deliver clearances/ instructions a bit slower

CASA GAAP HAZID Worksheet Location Name: Parafield SER

HAZARD/ ISSUE

PROPOSED SOLUTION / MITIGATOR

10

Hazard at Tailem Bend NDB – only NDB in the area for IFR practise. Too busy.

- Re-instate Ardrossan NDB

11

Varying instructor experience level

- Induction program for new instructors on local conditions/ procedures - Include a visit to the aerodrome tower for new instructor orientation

12

Instructors not receiving standard training (experiential capability) – standard will continue to decline if not addressed

- FTTO is addressing this with CFI’s

13

Airport signage is non-ICAO compliant eg. No lights at taxing/ runway 26 undershoot holding points

- Install holding point lights

14

Entry to GAAP: entry points, limited airspace- proximity of entry and exit points to the zone

- East – entry points are being changed in Nov 09

- Need for commonality of training

- West – more airspace becoming available in Nov 09 - Air traffic are using vertical separation as a compensator

15

No ATC entry clearance (rare occurrence)

- FTA and UniSA procedure out to the West – look at something similar to the East

16

Joining the circuit

- ATC procedure for arriving traffic - circuit aeroplanes to full stop - Education and awareness - To give ATC more flexibility/ discretion with the cap

17

Different aeroplane types

- There is a local procedure in place (i.e. Citation approaches and departs slower than usual)

18

Circuit training

- Education and awareness of requirements for non standard circuits

- Seeing other aeroplanes and identifying them

- Safety Forum – outcomes: RAPAC forum - Publish minutes on website from Safety Forum (CASA GAAP portal) - Support from the ATC tower, better training for pilots - Aeroplanes to operate with lights on - Consideration for training operators to look at aeroplane colour schemes 19

Radio procedures and communication

- Introduction of SMC has improved situation - Accuracy of calls with actual positions

20

Aerodrome layout

- Improve signage - Extend taxiway A to threshold of 03L

57

PART 1 APPENDIX C

Introduction Invitation to attend & Background – GAAP Directions to HAZID Workshops HAZID Workshop

59

APPENDIX C:



60


 61

APPENDIX D

Glossary of Terms

63

APPENDIX D:

Glossary of Terms

64

2RN

an IRP for Bankstown

ADC

Aerodrome Control/Controller

ADS-B

Automatic Dependent Surveillance – Broadcast

AF

Archerfield Aerodrome

AIP

Aeronautical Information Publication

ALA

Authorised Landing Area

ALARP

As Low As is Reasonably Practical

AOC

Air Operator’s Certificate

AOI

Airways Operations Instructions (now MATS)

AOPA

AOPA Aircraft Owners and Pilots Association

AS/NZS 4360: 2004

Australian/New Zealand Standard on Risk Management, 2004

ASA

Air Safety Advisor (CASA)

ASIR

Air Safety Investigation Report

ATC

Air Traffic Control/Controller

ATM

Air Traffic Management

ATPL

Airline Transport Pilot’s Licence

ATS

Air Traffic Services

ATSB

Australian Transport Safety Bureau

BASI

Bureau of Air Safety Investigation (now ATSB)

BK

Bankstown Aerodrome

CAR

Civil Aviation Regulation

CASA

Civil Aviation Safety Authority

CASR

Civil Aviation Safety Regulations

CCT

Circuit/Circuit Area

Class 1B

Airprox Airservices Australia ESIR Category (aeroplanes in close proximity, or avoiding action required to prevent a MAC)

CN

Camden Aerodrome

CRMF

Common Risk Management Framework

CTA

Control Area

CTAF

Common Traffic Advisory Frequency

CTAF(R)

Common Traffic Advisory Frequency (Radio Required)

CTR Control Zone

Control Zone

ERSA

En Route Supplement Australia (AIP)

ESL

English as a Second Language

ESOL

English for Speakers of Other Languages

EUROCAT Airservices’

Air Traffic Control System

FOI

Flying Operations Inspector (CASA)

FTO

Flight Training Organisation(s)

GA

General Aviation

GAAP

General Aviation Aerodrome Procedures

HAZID

Hazard Identification

IFR

Instrument Flight Rules

ILS

Instrument Landing System

IMC

Instrument Meteorological Conditions

IRP

GAAP aerodrome Inbound Reporting Point

MAC

Mid air Collision

MATS

Manual of Air Traffic Services

MBZ

Mandatory Broadcast Zone

MFD

Multii-Function Display

MOS

Manual of Operating Standards

NOTAM

Notice to Airmen

OAR

Office of Airspace Regulation (CASA)

OCTA

Outside Controlled Area/Airspace (i.e. Class G)

PIC

Pilot in Command

PPL

Private Pilot’s Licence

PSP

Prospect Reservoir – an IRP for Bankstown

RAPAC

Regional Airspace Procedures and Advisory Committee

RI

Runway Incursion

RPT

Regular Public Transport

RT

Radio Telephony

RWY Runway

RWY Runway

S&A

See and Avoid

SARPs

Standards and Recommended Practices (ICAO)

SATC

Senior Air Traffic Controller (now ATC Manager)

SMC

Surface Movement Control/Controller

SMS

Safety Management System

TAAATS

The Australian Advanced Air Traffic Services

TAS

Traffic Advisory System

TCAS

Traffic Collision Avoidance System

TIS

Traffic Information System

TIS-B

Traffic Information System – Broadcast

TMU

Terminal Control Unit

TSAD

Tower Situational Awareness Device

TWR

Air Traffic Control Tower

TWRN 2 RN

an IRP for Bankstown

VCA

Violation of Controlled Airspace

VFG

Visual Flight Guide

VFR

Visual Flight Rules

VMC

Visual Meteorological Conditions

VPG

Visual Pilot Guide

VTC

Visual Terminal Chart (AIP)

YBAF

Archerfield Aerodrome

YMMB

Moorabbin Aerodrome

YPJT

Jandakot Aerodrome

YPPF

Parafield Aerodrome

YSBK

Bankstown Aerodrome

YSCN

Camden Aerodrome

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APPENDIX E

References Airservices Australia, 2003, Review into General Aviation Aerodrome Procedures, Canberra, ACT Ambidji Group Pty Ltd (Ambidji), in conjunction with Lloyd’s Register, 2009, Utility of General Aviation Aerodrome Procedures to Australian-administered Airspace (Report to CASA’s the Office of Airspace Regulation), June 2009. CASA media release, ‘Improved safety at GAAP Aerodromes’, Ref: MR0966, July 2009. CASA, GAAP Changes FAQ, CASA website CASA, GAAP Changes Booklet, August 2009 CASA, Direction – all pilots operating at GAAP aerodromes, CASA directive No. 329/09, 21 July 2009 CASA, Direction – Airservices Australia, CASA directive No. 330/09, 21 July 2009 CASA, General Aviation Aerodrome Procedures Training Review, May 2009 CASA Minute of 9 Sept 09 ‘GAAP Risk Management (HAZID) Workshops - Terms of Reference’. CASA, GAAP Safety Education, letter from the Director Aviation Safety to Aviation Stakeholders, 3 August 09, Ref No. G/09/557 Civil Aviation Safety Authority, 2008, Functional Audit of GAAP Aerodromes, Canberra, ACT GAAP Changes FAQ question., 4. ‘Will the changes to procedures really have an impact on safety?‘ (CASA, 2009). http://www.casa.gov.au/wcmswr/_assets/main/corporat/research/gaap_training.pdf

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