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INVESTIGATION OF AIR TRAFFIC SERVICES General It may be desirable because of the circumstances associated with the occurrence to form a separate Air Traffic.

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Presentation on theme: "INVESTIGATION OF AIR TRAFFIC SERVICES General It may be desirable because of the circumstances associated with the occurrence to form a separate Air Traffic."— Presentation transcript:

1 INVESTIGATION OF AIR TRAFFIC SERVICES General It may be desirable because of the circumstances associated with the occurrence to form a separate Air Traffic Services Group which includes an Air Traffic Services specialist investigator. Where a State does not employ or have access to an Air Traffic Services specialist investigator an experienced (and non-involved) Air Traffic Services officer may be considered to provide specialist advice and assist the IIC to investigate all aspects of Air Traffic Services in relation to the occurrence. It may be convenient and practicable to include other related areas, such as, Communications, Aerodrome Facilities, and Navigation (in so far as the latter is concerned with ground equipment) within the sphere of the investigation to be conducted. In preparation of the Final Report, relevant factual information derived from the Air Traffic Services investigation may be inserted into the applicable section(s) as appropriate.

2 It may be necessary to investigate the efficiency and effectiveness of the Air Traffic Service, particularly in an occurrence involving aircraft proximity violations in the air or on the maneuvering area. In this event the following aspects should be considered and closely examined: a) Siting of and visibility from the control tower b) adequacy of accommodation of associated ATS centres and units c) ATS personnel, including appropriate number, qualifications (licenses) and supervision of personnel d) work and rest schedules of ATS personnel e) adequacy of specified procedures and practices including the provision of separation minima depending on the approval status of the aircraft in RVSM airspace f) adequacy of equipment including ATS surveillance systems, signal lights, binoculars and anti-glare devices.

3 Determination of the precise time of the occurrence is important. It is likely that the first indication of the approximate time of the occurrence will be obtained from the Air Traffic Service centres and units in communication with the flight. When the transcripts of the radiotelephony communication recordings become available it is usually possible to establish within about one minute the time of the occurrence. Sometimes greater accuracy is possible. If the aircraft was fitted with equipment such as a flight data recorder, a voice recorder or automatic dependent surveillance equipment it will normally be possible to narrow down the occurrence time to within one or two seconds. It is of importance to determine the time period to be examined by the investigation as this will define the extent of data, records and personnel involvement.

4 In the event of an occurrence involving flight into terrain, the recordings of a seismometer, located sufficiently close to the occurrence site to detect the impact, may be available to establish the time of the occurrence with great accuracy. Every effort should be made to determine as precisely as possible the time of an occurrence in order to be able to make use of information derived from the synchronization of recorders with the time base of the radiotelephony recording.

5 More and more the ATM system is gaining complexity. The traditional methods of science and analytical philosophy are not sensitive enough to the dynamics of complex ATM systems. Analytical methods, deductive logic, formal rule- based procedures, closed algorithms, may not be sufficient to complete an occurrence investigation. A connectionist approach will be necessary, because this approach is intrinsically more sensitive to the complexity of the ATM system envisaged by the Global ATM Operational Concept. Some key characteristics that will contribute to the complexity of the ATM system will be its distributedness, self- organization and the operation on local information without central control. On the other hand, the availability of a system wide information management will help the data collection necessary for the investigation.

6 Personnel Histories A study of all the facts pertaining to the Air Traffic Services forms an important part of both the Air Traffic Service investigation and may also be relevant to specific Operations and Human Factors investigations. Because these aspects are closely related, a high degree of co-ordination in the collection and evaluation of the relevant facts is required to achieve the best possible use of the information collected

7 Personal Record The following personal information should be obtained in respect of each Air Traffic Service officer involved in the occurrence: a) full name b) contact address and telephone number/s c) date of birth d) type of air traffic services license/certificate e) total length of service f) length of continuous service at relevant location g) ratings held and date/s obtained h) operating position occupied at the time of the occurrence i) proficiency check records j) medical history (recent illness, last medical examination, investigation of fatigue factor including an assessment of duty time and rest time within the 28 days preceding the occurrence and particularly within the last week and last 72 hours) k) initial and continuation training (including assessments) l) use of corrective and/or anti-glare lenses

8 Activity before, during and after the occurrence The evaluation of the Air Traffic Services personnel activities should done the same as the evaluation of the personnel activities in the Operations and Human Factors investigations. The following should be considered: a) Before the occurrence. The Air Traffic Services investigation should examine specifically: i) activities within the 72 hours prior to the occurrence with particular reference to psychological factors that might have a bearing on the performance of the relevant Air Traffic Services personnel, their physical condition in relation to the work/rest cycle and meal irregularity and an assessment of their sleep patterns ii) circumstances such as distance travelled in the journey to the location of the Air Traffic Services centres and units including preparation activity prior to commencing duty iii) the activities and workload since commencing duty at the workstation. This information canusually he obtained and substantiated from statement and/or hard copy and/or electronic data recordings

9 b) During the occurrence. In the light of the information obtained above, the investigation should endeavour to reconstruct the role, workload and behaviour of each of the relevant Air Traffic Services personnel during the sequential phases of the occurrence itself. It may also be relevant to examine, in conjunction with the Human Factors Group, the contribution made by such factors as the workstation layout, the operating environment, flight progress display, facilities presentation and controls, etc. c) After the occurrence. The role of the Air Traffic Service investigation and the information useful for the conduct of the investigation may not be limited to establishing the history of the flight and of the occurrence. The activities of the Air Traffic Services personnel immediately following the occurrence such as the organization of search and rescue where relevant, relief from operational duty etc. should be evaluated.

10 Flight Planning Where it is necessary to investigate the efficiency and effectiveness of the flight planning processes, the following aspects should be considered: a) flight planning requirements b) flight plan submission, type and content c) operation planned d) operational information obtained/provided

11 Airways Facilities The Air Traffic Services investigation should also address and report upon all factual information relating to the operational status and serviceability of the airways facilities in the period before, during, and after the occurrence. In doing so, the Air Traffic Services investigation should establish, record and verify the accuracy of all relevant information by use of a check list. Some or all of the following items may be relevant depending upon the relevant airways facilities and technology status: a) aeronautical information processing b) meteorological information displays c) surveillance data processing d) flight data processing e) local and wide area data processing

12 f) aeronautical fixed telecommunications network g) aeronautical telecommunications network h) aeromobile ground/air/ground voice communication and data links i) inter and intra-unit voice communication and data links j) local and remote facility monitoring and status register k) dynamic air route planning and processing l) satellite navigation and communications m) conflict/collision probe and avoidance

13 MID TERM ASSIGNMENT US Airways Flight 1549 A320-214 Landed in the Hudson River Weehawken, New Jersey January 15,2009. why this accident occurred. Do you think Pilot could avert this occurrence by using its professional expertise

14 The Boeing 747SR (Short Range) is an aircraft that was designed to be used on short, high-density routes. Due to its lower fuel capacity, it is capable of carrying over 550 passengers. For Japan Airlines 747SR, JA8119, Monday August 12, 1985 began no different than any other day. The aircraft had previously flown in from Kyushu and had arrived back at Haneda, Tokyo at 5:17 p.m. The aircraft was refuelled and new flight crew boarded, while the cabin crew remained from the previous flight. The only anamoly on this flight was that the First Officer was being upgraded by a Check Captain for promotion himself to Captain. JAL123, which was the assigned flight number for this trip, taxiied away from the gate at 6:04pm with 509 passengers on board, ready for the flight to the industrial city of Osaka which was 400km away.

15 In command of this flight was Captain Masami Takahama, 49, who was a Training Captain and had been with the company for nineteen years. He had 12,500 hours of total flight time. The flight took off at 6:12pm, and five minutes later while climbing on track to FL240 in visual conditions asked Tokyo ATC for a more direct route to Osaka. Tokyo Approved this request. Six minutes later as Tokyo ATC was tracking the flight, the emergency transponder code appeared on their screen, which was 7700. This is the emergency sqawk for aircraft in distress.

16 The controller noticed that instead of making the 177° turn back toward Oshima Island, the aircraft was making only a gradual turn to the right onto a course of 50°. Crossing the Izu Peninsula and leaving it astern, it then headed out over Suruga Bay in a north-westerly direction. The aircraft had suffered an explosive decompression of its rear vertical tail plane, losing a 15 foot section of the leading edge and having all its flying controls rendered useless. The aircraft impacted the lower slopes of Mount Osutaka, killing all but four people on board. The cause was found to be an improperly repaired rear pressure bulkhead, which had been repaired by Boeing some years before after the aircraft had been involved in a tail scrape on landing. This caused the loss of the flying surfaces in the tail, and the control surfaces to a certain extent on the wings. This was and still is the worlds worst accident involving a single airliner











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