RASMAG/16−WP/09 20-24/02/2012 International Civil Aviation

RASMAG/16−WP/09 20-24/02/2012

International Civil Aviation Organization

The Sixteenth Meeting of the Regional Airspace Safety Monitoring Advisory Group (RASMAG/16) Bangkok, Thailand, 20 – 24 February 2012

Agenda Item 3: Reports from Asia/Pacific RMAs and EMAs

SAFETY ASSESSMENT OF RVSM WITHIN THE FLIGHT INFORMATION REGIONS MONITORED BY THE AAMA

(Presented by Australia)

SUMMARY

This paper presents the results of safety assessments undertaken by the Australian Airspace Monitoring Agency (AAMA) for the twelve month period ending 30 November 2011. The assessments cover the Brisbane, Honiara, Jakarta, Melbourne, Nauru, Port Moresby and Ujung Pandang FIRs. Additional risk values are provided for months post the November period.

This paper relates to –

Strategic Objectives: A: Safety – Enhance global civil aviation safety

Global Plan Initiatives: GPI-2 Reduced vertical separation minima

1. INTRODUCTION

1.1. This paper provides details of the two airspace safety oversight assessments undertaken by the AAMA for the RVSM implementations in the Australian, Nauru, Papua New Guinea and Solomon Islands RVSM airspace to end of November 2011 and for the Indonesian airspace to end of September 2011. No full report was completed for October or November 2011 for Indonesia. The reports are detailed in Attachments 1 and 2.

2. DISCUSSION

2.1 The reports show that for the Australian, Nauru and Solomon Islands airspace, the target level of safety (TLS) was met. For the Indonesian airspace, the risk continued to exceeded the target. No assessment was completed for the Papua New Guinea airspace in November.

2.2 Since the completion of the assessments provided with this paper, the AAMA has completed further assessments for the month of December 2011 and January 2012 for the Australian, Nauru, Papua New Guinea and Solomon Islands airspace. The Papua New Guinea airspace has been integrated into this RVSM risk assessment effective January 2012. These RASMAG/16−WP/09 2 assessments show that the assessed risk for the period to end of January 2012 has increased since November to approximate 4.84E-9.

2.3 For the Indonesian airspace, assessments have been completed up to December 2011. The total risk for November 2011 approximated 5.62E-9 and has reduced marginally since then to be 5.47E-9 at end of December.

2.4 The AAMA continues to be well supported by both the Indonesian DGCA and the two air navigation service providers, and by CAA PNG and the Papua New Guinea air navigation service provider. The AAMA works closely with these authorities to improve reporting of operational error and the accuracy of traffic sample data.

3. ACTIONS BY THE MEETING

3.1 The meeting is invited to note and discuss the results of the airspace safety oversight presented in this working paper and the attached documentation.

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AUSTRALIAN AIRSPACE MONITORING AGENCY (AAMA)

SAFETY & ASSURANCE GROUP

SAFETY SYSTEMS, RISK & ANALYSIS

Operational Analysis Unit

Airspace Safety Review of the RVSM Implementation in Australian, Nauru and Solomon Islands Airspace December 2010 to November 2011

Australian Airspace Monitoring Agency – RVSM Safety Assessment Report Brisbane, Honiara, Melbourne and Nauru FIRs December 2010 to November2011

Executive Summary

For the period 1 December 2010 to 30 November 2011, the technical risk satisfies the agreed TLS value of no more than 2.5 x 10-9 fatal accidents per flight hour due to the loss of a correctly established vertical separation standard of 1,000 ft and to all causes. As depicted in the graph below, the operational and weighted total risk of 3.93 x 10-9 meets the specified TLS value for these components of 5.0 x 10-9.

Vertical Collision Risk by Type RVSM Implementation in the Brisbane, Honiara, Melbourne and Nauru FIRs

6.0E-9

5.0E-9

4.0E-9

3.0E-9

2.0E-9

1.0E-9

000.0E+0 Jul-11 Jan-11 Jun-11 Oct-11 Sep-11 Feb-11 Apr-11 Dec-10 Mar-11 Aug-11 Nov-11 May-11

Technical Risk Operational Risk Total Risk

TLS for Technical Risk TLS for Total Risk

The risk this month remains below the TLS.

Nine non-Nil large height deviation reports were reported during November 2011.

Two Category B (Flight Crew climbing/descending without ATC clearance) reports were filed. ESIR 2011 4664 was filed by Enroute ML-SY and was assessed in terms of number of levels crossed rather than assigning a time duration. A second report, ESIR 2011 4394 was filed by BASS and was the result of a crew commencing descent without a clearance. The duration was assessed as 0.5 minutes.

Two Category D reports (ATC system loop error; e.g. ATC issues incorrect clearance or flight crew misunderstands clearance message) were assessed. The report was filed by Enroute ML-SY (ESIR 2011 4639) and concerned a crew descending the aircraft as a result of incorrect phraseology used by a controller. This report was assessed in terms of 2 levels crossed rather than assigning a time duration. The second report ESIR 2011 4680 was filed by REEF and involved a controller issuing a climb instruction to the wrong aircraft. The duration was assessed as 0.5 minutes.

Australian Airspace Monitoring Agency – RVSM Safety Assessment Report Brisbane, Honiara, Melbourne and Nauru FIRs - 3 - December 2010 to November 2011 Four Category E reports (Coordination errors in the ATC-to-ATC transfer of control responsibility as a result of human factors issues) were reported, all attributed to ATS- FOREIGN. The total duration for the four reports was assessed as 12 minutes duration.

One Category L report (An aircraft being provided with RVSM separation is not RVSM approved) was filed by West Radar (ESIR 2011 4435). This report was assigned a duration of 10 minutes.

Australian Airspace Monitoring Agency – RVSM Safety Assessment Report Brisbane, Honiara, Melbourne and Nauru FIRs - 4 - December 2010 to November 2011 AIRSPACE SAFETY REVIEW OF THE RVSM IMPLEMENTATION IN AUSTRALIAN, NAURU AND SOLOMON ISLANDS AIRSPACE DECEMBER 2010 TO NOVEMBER 2011

Prepared by Australian Airspace Monitoring Agency (AAMA) – December 2011 (An ICAO APANPIRG approved Regional Monitoring Agency) ______1. Introduction

1.1 This report provides the summary of airspace safety oversight for the post RVSM implementation in the Australian, Nauru and Solomon Islands airspace, i.e. the total areas of the Brisbane, Honiara, Melbourne and Nauru FIRs. The RVSM safety oversight is conducted on a twelve month rolling assessment period.

2. Data Submission

2.1 Traffic Sample Data (TSD). A TSD covering four weeks of the month of December 2010 of aircraft operating in the Australian, Nauru and Solomon Islands airspace was used to assess the safety of RVSM airspace, as required by an ICAO Regional agreement between monitoring agencies.

2.2 Large Height Deviation (LHD). A series of cumulative 12-months of LHD reports were used in this safety assessment, covering December 2010 to November 2011.

3. Summary of LHD Occurrences

3.1 Table 1 and Figure 1 summarise the number of LHD occurrences assessed and associated LHD duration (in minutes) by month from 1 December 2010 inclusive.

No. of Non-NIL LHD Duration Month-Year LHD (Min) 2010 December 6 7.5 2011 January 5 6.0 February 11 37.5 March 4 6.5 April 5 3.5 May 6 9.0 June 1 0.5 July 3 40.0 August 2 3.5 September 10 15.0 October 4 7.0 November 9 23.0 Total 66 159.0

Table 1: Summary of Non-NIL LHD Occurrences and Duration

Australian Airspace Monitoring Agency – RVSM Safety Assessment Report Brisbane, Honiara, Melbourne and Nauru FIRs - 5 - December 2010 to November 2011 Summary of LHD Occurrences in Australian, Nauru and Solomon Islands RVSM Airspace Dec10-Nov11 45 40 35 30 25 20 15 10 5 0 Dec Jan Feb Mar Apr May June July Aug Sep Oct Nov

No of Non-NIL LHDs Duration of LHDs (Min)

Figure 1: Summary of LHD Occurrences (by Month)

3.2 Nine non-Nil LHDs were reported for the month of November which is more than twice the number reported in October. Additionally the assessed durations totaled this month 23 with two reports assessed on the basis of levels crossed in lieu of time. (See Table 1 and Figure 1).

3.3 Table 2 and Figure 2 summarise the number of LHD occurrences, the associated LHD duration (in minutes) and number of flight levels crossed without clearance, by LHD category from 1 December 2010 inclusive.

No. levels LHD LHD No. of LHD crossed Category LHD Category Description Duration Occurrences without Code (Min) clearance Flight crew failing to climb/descend A the aircraft as cleared 11 13.5 7

Flight crew climbing/descending B without ATC Clearance 15 48 4 Incorrect operation or interpretation of airborne equipment (e.g. incorrect operation of fully functional FMS, incorrect transcription of ATC C clearance or re-clearance, flight plan 1 1 0 followed rather than ATC clearance, original clearance followed instead of re-clearance etc)

Australian Airspace Monitoring Agency – RVSM Safety Assessment Report Brisbane, Honiara, Melbourne and Nauru FIRs - 6 - December 2010 to November 2011 ATC system loop error; (e.g. ATC issues incorrect clearance or flight D 7 8 5 crew misunderstands clearance message) Coordination errors in the ATC to ATC transfer or control responsibility as a result of human factors issues (e.g. late or non-existent E 17 67 0 coordination, incorrect time estimate/actual, flight level, ATS route etc not in accordance with agreed parameters) Coordination errors in the ATC to ATC transfer or control responsibility F as a result of equipment outage or 1 3 0 technical issues

Deviation due to aircraft contingency event leading to sudden inability to G maintain assigned flight level (e.g. 0 0 0 pressurization failure, engine failure)

Deviation due to airborne equipment H failure leading to unintentional or 2 1.5 0 undetected change of flight level Deviation due to turbulence or other I weather related cause 10 6.5 3 Deviation due to TCAS resolution J advisory, flight crew correctly 0 0 0 following the resolution advisory

Deviation due to TCAS resolution K advisory, flight crew incorrectly 0 0 0 following the resolution advisory

An aircraft being provided with RVSM separation is not RVSM approved (e.g. flight plan indicating L RVSM approval but aircraft not 1 10 0 approved, ATC misinterpretation of flight plan) Other – this includes situations of flights operating (including climbing/descending) in airspace M where flight crews are unable to 1 0.5 0 establish normal air-ground communications with the responsible ATS unit. Total 66 159 19

Table 2: Summary of LHD Occurrences and Duration by LHD Category

Australian Airspace Monitoring Agency – RVSM Safety Assessment Report Brisbane, Honiara, Melbourne and Nauru FIRs - 7 - December 2010 to November 2011

Summary of LHD Causes in Australian, Nauru and Solomon Islands RVSM Airspace Dec10-Nov11 80 70 60 50 40 30 20 10 0 ABCDEFGH I JKLM

No of Non-NIL LHDs Duration of LHDs (Min)

Figure 2: Summary of LHD Causes

3.4 Nine non-Nil large height deviation reports were reported during November 2011.

3.5 Two Category B (Flight Crew climbing/descending without ATC clearance) reports were filed. ESIR 2011 4664 was filed by Enroute ML-SY and was assessed in terms of number of levels crossed rather than assigning a time duration. A second report, ESIR 2011 4394 was filed by BASS and was the result of a crew commencing descent without a clearance. The duration was assessed as 0.5 minutes.

3.6 Two Category D reports (ATC system loop error; e.g. ATC issues incorrect clearance or flight crew misunderstands clearance message) were assessed. The report was filed by Enroute ML-SY (ESIR 2011 4639) and concerned a crew descending the aircraft as a result of incorrect phraseology used by a controller. This report was assessed in terms of 2 levels crossed rather than assigning a time duration. The second report ESIR 2011 4680, was filed by REEF and involved a controller issuing a climb instruction to the wrong aircraft. The duration was assessed as 0.5 minutes.

3.7 Four Category E report (Coordination errors in the ATC-to-ATC transfer of control responsibility as a result of human factors issues) were reported, all attributed to ATS- FOREIGN. The total duration for the four reports was assessed as 12 minutes duration.

3.8 One Category L report (An aircraft being provided with RVSM separation is not RVSM approved) was filed by West Radar (ESIR 2011 4435). This report was assigned a duration of 10 minutes.

Australian Airspace Monitoring Agency – RVSM Safety Assessment Report Brisbane, Honiara, Melbourne and Nauru FIRs - 8 - December 2010 to November 2011 4. Risk Assessment and Safety Oversight

4.1 This section updates the results of safety oversight for the RVSM implementation in the Australian, Nauru and Solomon Islands airspace. Accordingly, the internationally accepted collision risk methodology is applied in assessing the safety of the airspace.

4.2 Estimate of the CRM Parameters. The value and source material for estimating values for each of the inherent parameters of the internationally accepted Collision Risk Model (CRM) used to conduct the safety oversight for the RVSM airspace are summarized in Table 3.

Parameter Description Value Average aircraft length 0.0228 NM DOM (Uni-directional) x 0.0273 NM DOM (Bi-directional) 0.0340 NM IND 0.0265 NM TAS (Uni-directional) 0.0250 NM TAS (Bi-directional) Average aircraft wingspan 0.0202 NM DOM (Uni-directional) y 0.0246 NM DOM (Bi-directional) 0.0317 NM IND 0.0244 NM TAS (Uni-directional) 0.0223 NM TAS (Bi-directional) Average aircraft height 0.0069 NM DOM (Uni-directional) z 0.0078 NM DOM (Bi-directional) 0.0094 NM IND 0.0079 NM TAS (Uni-directional) 0.0075 NM TAS (Bi-directional) V Average relative same- 29.9 kts DOM (Uni-directional) direction speed 23.3 kts DOM (Bi-directional) 21.1 kts IND 22.4 kts TAS (Uni-directional) 19.5 kts TAS (Bi-directional) V Average aircraft speed 449.0 kts DOM (Uni-directional) 468.7 kts DOM (Bi-directional) 479.7 kts IND 461.5 kts TAS (Uni-directional) 460.6 kts TAS (Bi-directional) y Average relative cross-track 13 kts  speed z Average relative vertical 1.5 kts if aircraft in level flight,  speed during loss of vertical 10 knots otherwise separation Probability two aircraft at the 0.353 DOM (Uni-directional) Pz 0 same nominal level are in 0.403 DOM (Bi-directional) vertical overlap 0.485 IND 0.409 TAS (Uni-directional) 0.386 TAS (Bi-directional)

Table 3: Estimates of the Parameters in the CRM

Australian Airspace Monitoring Agency – RVSM Safety Assessment Report Brisbane, Honiara, Melbourne and Nauru FIRs - 9 - December 2010 to November 2011

4.4 Safety Oversight for the RVSM implementation in Australian, Nauru and Solomon Islands Airspace. The results of the airspace safety oversight in terms of the technical, operational, and total risks for the RVSM implementation are detailed in Table 4.

Australian, Nauru and Solomon Islands RVSM Airspace – estimated annual flying hours = 576,827.98 hours (note: estimated hours based on December 2010 traffic sample data) Source of Risk Risk Estimation TLS Remarks Technical Risk 0.029 x 10-9 2.5 x 10-9 Below Technical TLS Operational Risk 3.90 x 10-9 - - Total Risk 3.93 x 10-9 5.0 x 10-9 Below Overall TLS

Table 4: Risk Estimates for the RVSM Implementation

4.5 In addition, Figure 3 presents the trends of collision risk estimates for each month using the appropriate cumulative 12-month of LHD reports since 1 December 2010.

Vertical Collision Risk by Type RVSM Implementation in the Brisbane, Honiara, Melbourne and Nauru FIRs

6.0E-9

5.0E-9

4.0E-9

3.0E-9

2.0E-9

1.0E-9

000.0E+0 Jul-11 Jan-11 Jun-11 Oct-11 Sep-11 Feb-11 Apr-11 Dec-10 Mar-11 Aug-11 Nov-11 May-11

Technical Risk Operational Risk Total Risk

TLS for Technical Risk TLS for Total Risk

Figure 3: Trends of Risk Estimates for RVSM Airspace

4.6 The technical risk satisfies the agreed TLS value of no more than 2.5 x 10-9 fatal accidents per flight hour due to the loss of a correctly established vertical separation standard of 1,000 ft and to all causes. As depicted in the graph above, the operational and weighted total risk meets the specified TLS value for these components of 5.0 x 10-9.

4.7 The AAMA assesses LHD occurrences (specifically operational errors) in the Australian, Nauru, and Solomon Islands RVSM airspace from the perspective of individual occurrence contribution to total risk. Additionally a monthly risk value is determined in an attempt to provide real-time information on actual risk without reliance on historical high-

Australian Airspace Monitoring Agency – RVSM Safety Assessment Report Brisbane, Honiara, Melbourne and Nauru FIRs - 10 - December 2010 to November 2011 time errors resident within the 12 month data sample. The data in Figure 4 below shows the monthly risk for November 2011 remains below the average monthly risk which gives an annual risk of 5.0 x 10-9 (red line in Figure 4 below).

Figure 4: Monthly Risk Estimates for the Australian, Nauru and Solomon Islands RVSM Airspace. Red line is the average monthly value for an annual risk of 5.0 x 10-9. Risk is measured in Fatal Accidents per Flight Hour (FAPFH).

The graph shown at Figure 5 below indicates the risk contribution from each of the areas assessed by the AAMA for the Australian FIRs. The percentage distribution has not changed from last month.

Figure 5: Risk Contribution by Traffic Region

Australian Airspace Monitoring Agency – RVSM Safety Assessment Report Brisbane, Honiara, Melbourne and Nauru FIRs - 11 - December 2010 to November 2011

5. Safety treatment of identified LHDs

Part of the assessment process should include a detailed review of specific operational errors by ANSPs with a view to identifying contributory factors and ensuring procedures and processes are implemented to reduce the likelihood of the same errors recurring. In the case of the Australian, Nauru and Solomon Islands airspace, the AAMA assessed operational errors identified through the Airservices Australia Electronic Safety Incident Reporting system and from aircraft operator reports. Figure 6 identifies the risk contribution by attribution for the operational errors and large height deviations in the twelve month data sample.

Figure 6: Risk Contribution by Attribution

5.1 Table 5 details those LHDs or operational errors that are assessed as being of high risk within the 12 month data set. A report filed in July 2011 contributes nearly 75% of the assessed risk for that month (see Figure 4) and approximately one fifth of the annual risk. In September ESIR 2011 3730 was the result of a foreign pilot not complying with a vertical requirement to ensure separation with an opposite direction aircraft. The pilot misunderstood the communication from the controller.

Australian Airspace Monitoring Agency – RVSM Safety Assessment Report Brisbane, Honiara, Melbourne and Nauru FIRs - 12 - December 2010 to November 2011

ESIR/ATSB MONTH RISK ATTRIBUTION Report CONTRIBUTION 2011 0647 FEB 1.02 x 10-9 ATS 2011 1962 MAY 0.41 x 10-9 PILOT FOREIGN 2011 2733 JUL 0.43 x 10-9 PILOT FOREIGN 2011 3730 SEP 0.27 x 10-9 PILOT FOREIGN

Table 5: Assessed High Risk LHD/Operational Errors

5.2 Figure 7 provides a visual picture of the geographic location of all risk bearing (non-NIL) LHD reports within the rolling 12 month data set. Each report is identified as a coloured dot. Reports assessed as being high risk during the current month of this report are identified as a red dot or a line showing approximate distance that equates to the assessed duration. The picture is intended to provide a means to identify specific risk hot spots related to RVSM operations.

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References

[1] Anderson, D.H. RVSM Safety Assessment for the Australian FIRs, Airservices Australia, Research Environment & Training Services, 21September 1999. [2] Summary of Pacific Reduced Vertical Separation Minimum (RVSM) Safety Assessment, Asia Pacific Approvals Registry and Monitoring Organization, December 2000. [3] Assurance of Safe Reduced Vertical Separation Minimum Implementation for Asia and Pacific Oceanic Airspace, Appendix E to the Report of the Second Meeting of the ICAO Reduced Vertical Separation Minima Implementation Task Force (RVSM/TF/2), Los Angeles, U.S.A, 1999. [4] Manual on Implementation of a 300 m (1 000 ft) Vertical Separation Minimum Between FL 290 and FL 410 Inclusive, ICAO Doc 9574-AN/934, FIRST EDITION – 1992. [5] Report of the Third Meeting of the ICAO Reduced Vertical Separation Minima Implementation Task Force (RVSM/TF/3), Honolulu, U.S.A, May 1999.

Australian Airspace Monitoring Agency – RVSM Safety Assessment Report Brisbane, Honiara, Melbourne and Nauru FIRs - 13 - December 2010 to November 2011

Figure 7: Brisbane, Honiara, Melbourne and Nauru FIRs – Risk Bearing (Non-NIL) RVSM Large Height Deviations December 2010 – November 2011

Non-NIL LHD Non-NIL LHD - current month High risk bearing LHD - current month

Australian Airspace Monitoring Agency – RVSM Safety Assessment Report Brisbane, Honiara, Melbourne and Nauru FIRs December 2010 to November2011

Vertical Collision Risk by Type RVSM Implementation in the Brisbane, Honiara, Melbourne and Nauru FIRs

12.0E-9

10.0E-9

8.0E-9

6.0E-9

4.0E-9

2.0E-9

000.0E+0 Jul-11 Jul-10 Jul-09 Jan-11 Jan-10 Jan-09 Jun-11 Jun-10 Jun-09 Oct-11 Oct-10 Oct-09 Sep-11 Feb-11 Sep-10 Feb-10 Sep-09 Feb-09 Apr-11 Apr-10 Apr-09 Dec-10 Dec-09 Dec-08 Mar-11 Mar-10 Mar-09 Aug-11 Nov-11 Aug-10 Nov-10 Aug-09 Nov-09 May-11 May-10 May-09

Technical Risk Operational Risk Total Risk

TLS for Technical Risk TLS for Total Risk

Figure 8: Brisbane, Honiara, Melbourne and Nauru FIRs – Vertical Collision Risk (December 2008 – November 2011)

Australian Airspace Monitoring Agency – RVSM Safety Assessment Report Brisbane, Honiara, Melbourne and Nauru FIRs - 15 - December 2010 to November 2011

AUSTRALIAN AIRSPACE MONITORING AGENCY (AAMA)

Airspace Safety Review of the RVSM Implementation in Indonesian Airspace

October 2010 to September 2011

Australian Airspace Monitoring Agency – RVSM Safety Assessment Report Jakarta and Ujung Pandang FIRs October 2010 to September 2011

Executive Summary

For the period 1 October 2010 to 30 September 2011, the technical risk satisfies the agreed TLS value of no more than 2.5 x 10-9 fatal accidents per flight hour due to the loss of a correctly established vertical separation standard of 1,000 ft and to all causes. As depicted in the graph below, the operational and weighted total risk of 6.43 x 10-9 does not meet the specified TLS value for these components of 5.0 x 10-9.

Vertical Collision Risk by Type RVSM Implementation in the Indonesian Airspace

9.E-09 8.E-09 7.E-09 6.E-09 5.E-09 4.E-09 3.E-09 2.E-09 1.E-09 0.E+00 Jul-11 Jan-11 Jun-11 Oct-10 Sep-11 Sep-10 Feb-11 Apr-11 Dec-10 Mar-11 Aug-11 Nov-10 May-11

Technical Risk Operational Risk Total Risk TLS for Technical Risk TLS for Total Risk

Australian Airspace Monitoring Agency – RVSM Safety Assessment Report Jakarta and Ujung Pandang FIRs October 2010 to September 2011

AIRSPACE SAFETY REVIEW OF THE RVSM IMPLEMENTATION IN INDONESIAN AIRSPACE – OCTOBER 2010 TO SEPTEMBER 2011

Prepared by

Australian Airspace Monitoring Agency (AAMA) - October 2011 (An APANPIRG approved Regional Monitoring Agency)

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1. Introduction

This report provides the summary of airspace safety oversight for the post RVSM implementation in the Asia Pacific Region, focusing on the Indonesian airspace, i.e. the total areas of the Jakarta and Ujung Pandang FIRs. The RVSM safety oversight is conducted based on a one-month traffic sample data (TSD) collected in December 2010 and monthly Large Height Deviation (LHD) reports between October 2010 and September 2011.

2. Data Submission

2.1. Traffic Sample Data (TSD)

Traffic Sample data for the month of December 2010 of aircraft operating in the Indonesian airspace was used for both the Jakarta and Ujung Pandang airspace.

2.2. Large Height Deviation (LHD)

A series of cumulative 12-months of LHD reports were used in this safety assessment starting from October 2010 to September 2011. A number of LHDs were received from the Indonesian Air Navigation Service Providers. Additionally the AAMA has access to reports provided by other States or Regional Monitoring Agencies (RMAs) that included possible risk bearing LHDs relative to the Jakarta and Ujung Pandang FIRs. Assessment of these reports is made from the perspective of their impact within the Indonesian airspace.

Australian Airspace Monitoring Agency – RVSM Safety Assessment Report Jakarta and Ujung Pandang FIRs October 2010 to September 2011

3. Summary of LHD Occurrences in Indonesian Airspace

Table 1 and Figure 1 summarise the number of LHD occurrences and associated LHD duration (in minutes) by month since October 2010 inclusive. The data is the total number of non-NIL LHDs assessed.

No. of Non- LHD Duration Month-Year NIL LHD (Min) Occurrences 2010 October 5 2.5 November 3 5.3 December 2 1.0 2011 January 3 4.0 February 6 2.3 March 4 1.0 April 2 0.5 May 2 1.5 June 2 1.5 July 3 4.5 August 2 2.5 September 1 0 Total 35 26.6

Table 1: Summary of Non-NIL LHD Occurrences and Duration in Indonesian RVSM Airspace

Summary of LHD Occurrences in Indonesian RVSM Airspace Oct 2010-Sep 2011 7 No of Non-NIL LHDs 6 Duration of LHDs (Min) 5

b r Jul Oct Nov Dec Jan Fe Mar Ap Jun Sep May Aug

Figure 1: Summary of LHD Occurrences (by Month) in the Indonesian RVSM Airspace

Table 2 and Figure 2 summarise the number of LHD occurrences and associated LHD duration (in minutes) by LHD category from 1 October 2010 inclusive.

Australian Airspace Monitoring Agency – RVSM Safety Assessment Report Jakarta and Ujung Pandang FIRs October 2010 to September 2011

LHD LHD No. of LHD Levels Category LHD Category Description Duration Occurrences Crossed Code (Min) Flight crew failing to climb/descend the A aircraft as cleared 4 1.4 1 Flight crew climbing/descending without B ATC Clearance 6 1.9 4 Incorrect operation or interpretation of airborne equipment (e.g. incorrect operation of fully functional FMS, incorrect transcription of ATC clearance C 0 0 0 or re-clearance, flight plan followed rather than ATC clearance, original clearance followed instead of re- clearance etc) ATC system loop error; (e.g. ATC issues incorrect clearance or flight crew D 1 0.5 0 misunderstands clearance message)

Coordination errors in the ATC to ATC transfer or control responsibility as a result of human factors issues (e.g. late E or non-existent coordination, incorrect 18 22.8 2 time estimate/actual, flight level, ATS route etc not in accordance with agreed parameters) Coordination errors in the ATC to ATC transfer or control responsibility as a F 0 0 0 result of equipment outage or technical issues Deviation due to aircraft contingency event leading to sudden inability to G maintain assigned flight level (e.g. 2 0 9 pressurization failure, engine failure) Deviation due to airborne equipment H failure leading to unintentional or 0 0 0 undetected change of flight level Deviation due to turbulence or other I weather related cause 0 0 0 Deviation due to TCAS resolution J advisory, flight crew correctly following 4 0 4 the resolution advisory Deviation due to TCAS resolution K advisory, flight crew incorrectly following 0 0 0 the resolution advisory An aircraft being provided with RVSM separation is not RVSM approved (e.g. L flight plan indicating RVSM approval but 0 0 0 aircraft not approved, ATC misinterpretation of flight plan)

Australian Airspace Monitoring Agency – RVSM Safety Assessment Report Jakarta and Ujung Pandang FIRs October 2010 to September 2011 Other – this includes situations of flights operating (including climbing/descending) in airspace where M flight crews are unable to establish 0 0 0 normal air-ground communications with the responsible ATS unit.

Total 35 26.6 20

Table 2: Summary of LHD Occurrences and Duration by LHD Category in Indonesian RVSM Airspace

Summary of LHD Causes in Indonesian RVSM Airspace Oct 2010-Sep 2011 25

No of Non-NIL LHDs 20 Duration of LHDs (Min)

0 ABCDEFGH I JKLM

Figure 2: Summary of LHD Causes in the Indonesian RVSM Airspace

The non-nil LHD occurrences in the Indonesian RVSM airspace are summarised as follows:

 Table 1 and Figure 1 show that the number and duration of LHDs reported during September continues to decrease compared to the previous two months. However the total number and duration of LHDs for the twelve month period increased.

 Figure 2 shows that Category E (ATC-to-ATC Coordination Errors) remain the largest contributing category in terms of operational errors. Both Category A and B pilot errors also remain notable contributing elements to risk in the airspace.

Australian Airspace Monitoring Agency – RVSM Safety Assessment Report Jakarta and Ujung Pandang FIRs October 2010 to September 2011  One non-NIL Category J (TCAS resolution advisory; flight crew correctly following the resolution advisory) LHD was reported during September. The report from Jakata ACC involved a TCAS event when a descending aircraft crossed the level of another aircraft cruising at FL330. The report was assessed on the basis of one level crossed instead of a time.

4. Risk Assessment and Safety Oversight

This section updates the results of safety oversight for the RVSM implementation in the Indonesian airspace. Accordingly, the internationally accepted collision risk methodology is applied in assessing the safety of the airspace. The Traffic Sample Data (TSD) of December 2010 and LHD reports associated with the airspace for a twelve month period are used to produce the risk estimates presented in this report.

4.1. Estimate of the CRM Parameters

Table 3 summarises the value and source material for estimating values for each of the inherent parameters of the internationally accepted Collision Risk Model (CRM) used to conduct the safety oversight for the RVSM airspace.

Parameter Description Value Average aircraft length 0.0243 NM (JAK) x 0.0259 NM (UJU) Average aircraft wingspan 0.0215 NM (JAK) y 0.0234 NM (UJU) Average aircraft height 0.0072 (JAK) z 0.0076 (UJU) V Average relative same- 17.3 kts (JAK) direction speed 30.22 kts (UJU) V Average aircraft speed 444.2 kts (JAK) 462.7 kts (UJU) y Average relative cross-track 13 kts  speed z Average relative vertical speed 1.5 kts if aircraft in level flight,  during loss of vertical 10 knots otherwise separation Probability two aircraft at the 0.35863 (JAK) Pz 0 same nominal level are in 0.42255 (UJU) vertical overlap

Table 3: Estimates of the Parameters in the CRM

4.2. Safety Oversight for the RVSM implementation in Indonesian Airspace

Table 4 summarises the results of the airspace safety oversight in terms of the technical, operational, and total risks for the RVSM implementation in the Indonesian airspace.

Indonesian RVSM Airspace – estimated annual flying hours = 556 078.09 hours (note: estimated hours based on Dec 2010 traffic sample data) Source of Risk Risk TLS Remarks Estimation Technical Risk 0.173 x 10-9 2.5 x 10-9 Below Technical TLS Operational Risk 6.25 x 10-9 - - Total Risk 6.43 x 10-9 5.0 x 10-9 Above TLS

Australian Airspace Monitoring Agency – RVSM Safety Assessment Report Jakarta and Ujung Pandang FIRs October 2010 to September 2011

Table 4: Risk Estimates for the RVSM Implementation in Indonesian Airspace

Figure 3 below presents the trends of collision risk estimates for the period from September 2010 to end of September 2011.

Vertical Collision Risk by Type RVSM Implementation in the Indonesian Airspace

9.E-09 8.E-09 7.E-09 6.E-09 5.E-09 4.E-09 3.E-09 2.E-09 1.E-09 0.E+00 Jul-11 Jan-11 Jun-11 Oct-10 Sep-11 Sep-10 Feb-11 Apr-11 Dec-10 Mar-11 Aug-11 Nov-10 May-11

Technical Risk Operational Risk Total Risk TLS for Technical Risk TLS for Total Risk

Figure 3: Trends of Risk Estimates for the Indonesian RVSM Airspace

Based on these collision risk estimates, the technical risk satisfies the agreed TLS value of no more than 2.5 x 10-9 fatal accidents per flight hour due to the loss of a correctly established vertical separation standard of 1,000 ft and to all causes. As depicted in table 4 above the operational and weighted total risk does not meet the specified TLS value for these components of 5.0 x 10-9.

The risk this month has increased marginally compared to the previous months assessment. This resulted primarily from an increase in the number and total duration of assessed LHDs.

5. Safety treatment of identified LHDs

5.1 Part of the assessment process should include a detailed review of specific operational errors by ANSPs with a view to identifying contributory factors and putting in place procedures and processes to reduce the likelihood of the same errors recurring. In the case of the Indonesian FIRs, the AAMA assesses LHDs forwarded to it by Indonesian ANSPs, the Airservices Australia Electronic Safety Incident Reporting system and other regional monitoring agencies.

5.2 Figure 4 provides a visual picture of the geographic location of all risk bearing (non- NIL) LHD reports within the rolling 12 month data set. Each report included in LHD reports filed by Indonesian ANSPs is identified as a red dot. Additional risk bearing reports used by the AAMA, such as reported by Airservices Australia, are identified in purple. Significant long

Australian Airspace Monitoring Agency – RVSM Safety Assessment Report Jakarta and Ujung Pandang FIRs October 2010 to September 2011 duration reports (identified as either a red or purple line) show the approximate distance that equates to the assessed duration. The picture is intended to provide a means to identify specific risk hot spots related to RVSM operations.

5.3 The cluster of LHDs located centrally at the boundary between the Jakarta and Ujung Pandang FIRs represents a number of risk bearing reports all related to Category E (coordination errors). There appear to be two areas where a number of coordination errors are repeated, these being around the waypoint SABIL and to the south near SEMARANG. Three LHDs identified on the northern boundary with Manila FIR at position MOLLY were errors attributed to Manila ACC but assessed as being risk bearing within the Ujung FIR.

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References

Australian Airspace Monitoring Agency – RVSM Safety Assessment Report Jakarta and Ujung Pandang FIRs October 2010 to September 2011

Figure 4: Jakarta and Ujung Pandang FIRs – Risk Bearing (Non-NIL) RVSM Large Height Deviations October 2010 – September 2011

Australian Airspace Monitoring Agency – RVSM Safety Assessment Report Jakarta and Ujung Pandang FIRs October 2010 to September 2011