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. ………………………………… 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.