RASMAG/15−WP/16 01-05/08/2011 International Civil Aviation

RASMAG/15−WP/16 01-05/08/2011

International Civil Aviation Organization

The Fifteenth Meeting of the Regional Airspace Safety Monitoring Advisory Group (RASMAG/15) Bangkok, Thailand, 1 – 5 August 2011

Agenda Item 3: Reports from Asia/Pacific RMAs

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

(Presented by Australia)

SUMMARY

This paper presents the results of three safety assessments undertaken by the Australian Airspace Monitoring Agency (AAMA) for the twelve month period ending 30 April 2011. The assessments cover the Brisbane, Honiara, Jakarta, Melbourne, Nauru and Ujung Pandang FIRs. An assessment for the Papua New Guinea airspace has not been finalised as at 30 April 2011.

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, Indonesian, Nauru and Solomon Islands RVSM airspace. The reports are detailed in Attachments 1 to 2.

2. Discussion

2.1 Since the completion of the April 2011 assessments provided with this paper, the AAMA has completed further assessments for the months of May and June 2011 for both the Australian and Indonesian airspace. These assessments show that in the Australian airspace, the number of Category A type LHDs has decreased by about 50% over the last few months however the total duration of these incidents has only reduced by approximately 20%. The assessed risk for the period to end of June 2011 approximates 3.49E-9.

2.2 For the Indonesian airspace, the number of Category E LHDs has remained unchanged in the two months following the April 2011 assessment however the total duration of these incidents has decreased by approximately 25%. The total risk has reduced marginally since April to be 6.18E-9 in the period to end of June 2011.

2.3 The AAMA is pleased to report that the on-going assistance it receives from the Indonesian DGCA and the two air navigation service providers is commendable and has enabled the AAMA to complete its monthly assessments in a timely manner. The AAMA undertakes visits to Indonesia twice a year with the sole purpose of reviewing the assessments with the DGCA and ANSP staff and to identify potential risk areas, assist with traffic sample data compilation, and aircraft approval and monitoring issues. The AAMA continues to work closely with these authorities to improve reporting of operational error and the accuracy of traffic sample data. RASMAG/15−WP/16 2

2.4 While the AAMA was able to provide a risk assessment for the Papua New Guinea airspace last year for the period ending April 2010, it has been unable to finalise an assessment for April 2011 at this point in time. Work will continue to make the assessment available prior to the next APANPIRG meeting so that the Secretariat can consider including the outcomes in the RASMAG report.

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. The AAMA requests RASMAG endorsement for it to circulate the subsequently completed risk assessment for Papua New Guinea airspace out of session and for the Secretary to nominate a date by which the material should be available for inclusion in the RASMAG report to APANPIRG.

………………………….

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 May 2010 to April 2011

Australian Airspace Monitoring Agency – RVSM Safety Assessment Report Brisbane, Honiara, Melbourne and Nauru FIRs May 2010 to April 2011

Executive Summary

For the period 1 May 2010 to 30 April 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 4.27 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

7.0E-9

6.0E-9

5.0E-9

4.0E-9

3.0E-9

2.0E-9

1.0E-9

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

Technical Risk Opera tio nal Ris k Total Risk TLS for Technical Ris k TLS for Total Ris k

The risk this month remains below the TLS.

Two Category B reports (ESIRs 2011 1471 filed by WEST RADAR, and 2011 1688 filed by BASS) were reported this month. One resulted from a pilot of an Australian registered aircraft descending before being cleared to do so and was assessed as 0.5 minutes duration. The other report resulted from a crew accepting a descent clearance intended for another aircraft. This report was assessed on the basis of number of levels crossed (2) rather than time duration.

Australian Airspace Monitoring Agency – RVSM Safety Assessment Report Brisbane, Honiara, Melbourne and Nauru FIRs - 3 - May 2010 to April 2011 AIRSPACE SAFETY REVIEW OF THE RVSM IMPLEMENTATION IN AUSTRALIAN, NAURU AND SOLOMON ISLANDS AIRSPACE MAY 2010 TO APRIL 2011

Prepared by Australian Airspace Monitoring Agency (AAMA) – May 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 May 2010 to April 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 May 2010 inclusive.

No. of Non-NIL LHD Duration Month-Year LHD (Min) 2010 May 9 9.0 June 10 15.5 July 5 3.5 August 5 53 September 8 9.5 October 6 52.0 November 3 6.5 December 6 7.5 2011 January 5 6.0 February 10 36.5 March 5 7.5 April 3 2.5 Total 75 209.0

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

Australian Airspace Monitoring Agency – RVSM Safety Assessment Report Brisbane, Honiara, Melbourne and Nauru FIRs - 4 - May 2010 to April 2011 Summary of LHD Occurrences in Australian, Nauru and Solomon Islands RVSM Airspace May10-Apr11 60

0 May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr

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

Figure 1: Summary of LHD Occurrences (by Month)

3.2 This month saw the number of LHDs reported decrease by nearly 50% from the last month while the total assessed duration decreased by nearly 70% (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 May 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 21 71 7

Flight crew climbing/descending B without ATC Clearance 12 8.5 5 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 5 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 - 5 - May 2010 to April 2011 ATC system loop error; (e.g. ATC issues incorrect clearance or flight D 5 41 2 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 22 70 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 0 0 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 0 0 0 undetected change of flight level Deviation due to turbulence or other I weather related cause 10 8 1 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 0 0 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 4 5.5 0 establish normal air-ground communications with the responsible ATS unit. Total (May 10 – Apr 11) 75 209 15

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 - 6 - May 2010 to April 2011

Summary of LHD Causes in Australian, Nauru and Solomon Islands RVSM Airspace May10-Apr11 80

60 50

20 10 0 ABCDEFGH I JKLM

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

Figure 2: Summary of LHD Causes

3.4 Two Category B reports (ESIRs 2011 1471 filed by WEST RADAR, and 2011 1688 filed by BASS) were reported this month. One resulted from a pilot of an Australian registered aircraft descending before being cleared to do so and was assessed as 0.5 minutes duration. The other report resulted from a crew accepting a descent clearance intended for another aircraft. This report was assessed on the basis of number of levels crossed (2) rather than time duration.

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.

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

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 4.24 x 10-9 - - Total Risk 4.27 x 10-9 5.0 x 10-9 Below Overall TLS

Table 4: Risk Estimates for the RVSM Implementation

Australian Airspace Monitoring Agency – RVSM Safety Assessment Report Brisbane, Honiara, Melbourne and Nauru FIRs - 8 - May 2010 to April 2011

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 May 2010.

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

7.0E-9

6.0E-9

5.0E-9

4.0E-9

3.0E-9

2.0E-9

1.0E-9

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

Technical Risk Opera tio nal Ris k Total Risk TLS for Technical Ris k TLS for Total Ris k

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- time errors resident within the 12 month data sample. The data in Figure 4 below shows the monthly risk for April 2011 remains well below the average monthly risk which gives an annual risk of 5.0 x 10-9 (red line in Figure 4 below).

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

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 - 10 - May 2010 to April 2011 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 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

5.2 Table 5 details those LHDs or operational errors that are assessed as being of high risk within the 12 month data set. One report filed in February 2011 contributes nearly 75% of the assessed risk for that month (see Figure 4) and approximately one fifth of the annual risk.

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

ESIR/ATSB MONTH RISK ATTRIBUTION Report CONTRIBUTION 2011 647 FEB 1.02 x 10-9 ATS

Table 5: Assessed High Risk LHD/Operational Errors

5.3 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.

5.4 The boundary between the Australian and Indonesian FIRs continues to show a number of reports, mostly all related to Category E coordination errors. There are a number of reports identified along the Colombo and Mauritius FIR boundaries where they interface with Melbourne FIR.

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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 - 12 - May 2010 to April 2011

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

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

14.0E-9

12.0E-9

10.0E-9

8.0E-9

6.0E-9

4.0E-9

2.0E-9

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

Technical Risk Operational Risk Total Risk TLS fo r Technical Ris k TLS for Total Risk

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

Australian Airspace Monitoring Agency – RVSM Safety Assessment Report Brisbane, Honiara, Melbourne and Nauru FIRs - 14 - May 2010 to April 2011

AUSTRALIAN AIRSPACE MONITORING AGENCY (AAMA)

Airspace Safety Review of the RVSM Implementation in Indonesian Airspace

May 2010 to April 2011

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

Executive Summary

For the period 1 May 2010 to 30 April 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 6.27 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-10 Jul-09 Jan-11 Jan-10 Jan-09 Jun-10 Jun-09 Sep-10 Oct-10 Feb-11 Sep-09 Oct-09 Feb-10 Feb-09 Dec-10 Dec-09 Dec-08 Aug-10 Apr-11 Aug-09 Apr-10 Apr-09 Nov-10 Mar-11 Nov-09 Mar-10 Nov-08 Mar-09 May-10 May-09

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 May 2010 to April 2011

AIRSPACE SAFETY REVIEW OF THE RVSM IMPLEMENTATION IN INDONESIAN AIRSPACE – MAY 2010 TO APRIL 2011

Prepared by

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

______

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 May 2010 and April 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 May 2010 to April 2011. A number of LHDs were received from the Indonesian Air Navigation Service Providers. Additionally the AAMA had access to a number of reports provided by Australia that included possible risk bearing LHDs relative to the Jakarta and Ujung Pandang FIRs. Assessment of these reports was made from the perspective of their impact within the Indonesian airspace.

Of note is that one Category E LHD was identified in data available from the Australian ESIR system (see below) that related to an error in coordination by a controller in Ujung FIR. No corresponding LHD was reported by the Ujung FIR for this incident when the AAMA would have expected one to have been reported.

070603 Ujung Pandang coordinated CPA163 via BUTPA at FL370. Coordination confirmed via audio replay. 0637 CPA163 enters coupling corridor for 2011 1476 201104070637 Indonesian ADS-B data sharing. CLAM alert with displayed FL390. Brisbane clarifies level which Ujung confirms as FL390. 0640 Ujung called back and apologised for incorrect level.

Australian Airspace Monitoring Agency – RVSM Safety Assessment Report Jakarta and Ujung Pandang FIRs May 2010 to April 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 May 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 May 2 9.0 June 0 0.0 July 0 0.0 August 0 0.0 September 2 4.0 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 Total 29 29.6

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

Summary of LHD Occurrences in Indonesian RVSM Airspace May 2010-Apr 2011 10 9 No of Non-NIL LHDs 8 Duration of LHDs (Min) 7 6 5 4 3 2 1 0

y p b e an e ar pr Jun Jul Aug Oct Nov J F M A Ma S Dec

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 May 2010 inclusive.

Australian Airspace Monitoring Agency – RVSM Safety Assessment Report Jakarta and Ujung Pandang FIRs May 2010 to April 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 3 1.4 0 Flight crew climbing/descending without B ATC Clearance 7 2.9 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 0 0 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 14 25.3 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 3 0 3 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 May 2010 to April 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 (May 10 – Apr11) 29 29.6 18

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

Summary of LHD Causes in Indonesian RVSM Airspace May 2010-Apr 2011 30 No of Non-NIL LHDs 25 Duration of LHDs (Min)

0 ABCDEFGH I JKLM

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

In light of the above, the non-nil LHD occurrences in the Indonesian RVSM airspace are summarised as follows:

 Figure 1 and Table 1 show a notable decrease in the number of non-NIL LHDs reported for April compared to the previous month. The total duration assessed from these LHDs was 50% less than the previous month. The duration of non-NIL LHDs has continued to reduce since January. Importantly one of the non-NIL LHDs reported in April was assessed in terms of levels crossed rather than duration.

 Figure 2 shows that Category E (ATC-to-ATC Coordination Errors) remain the largest contributing category in terms of operational errors.

Australian Airspace Monitoring Agency – RVSM Safety Assessment Report Jakarta and Ujung Pandang FIRs May 2010 to April 2011  One non-NIL Category E (ATC Coordination errors) LHD was reported by Ujung and involved Jakarta ACC climbing an aircraft without coordination to Ujung. The aircraft was observed passing FL377, a 1700 feet deviation from its coordinated level of FL360. No time was used for this report as it was assessed on the basis of 2 flight levels crossed.

 One Category B LHD (Flight Crew climbing/descending without ATC clearance) was reported by Ujung and involved an aircraft descending from FL 350 without clearance. The aircraft was passing FL343 when identified by ATC with other traffic in the vicinity at FL340. This report was assessed as 0.5 minute duration.

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 the LHD reports associated with the airspace during the period May 2010 to April 2011 (inclusive) 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

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

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 6.10 x 10-9 - - Total Risk 6.27 x 10-9 5.0 x 10-9 Above TLS

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 November 2008 to end of April 2011.

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 the risk weighting applied to the type of LHDs reported for the month.

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

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 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). Another LHD identified on the northern boundary with Manila FIR was an error 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 May 2010 to April 2011

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

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