SURVEILLANCE REPORT
Airservices Australia
ARN: 202210
Part 172
Level 2 Site Inspection - SY TCU
Surveil ance Dates: 14/06/2022 to 11/07/2022
Executive Summary
This Surveil ance Report outlines the results of a level 2 Site Inspection surveil ance event
No. 24241 conducted on Part 172 Air Traffic Services holder - Airservices Australia -
Certificate CASA.172.0005 Revision No. 2.
Part 172 of Civil Aviation Safety Regulations 1998 (CASR) specifies the regulatory
framework for the approval of air traffic services providers. It includes standards for air
traffic facilities, safety management and the provision of air traffic services. Surveil ance
was conducted on the provision of Approach Control Service by Sydney Terminal Control
Unit (TCU).
The previous surveil ance event carried out was a level 1 surveil ance conducted between
24 and 28 July 2019 at the authorisation holder’s Sydney TCU premises. During that
event, one Safety Finding and three Safety Observations were issued. The authorisation
holder did not provide third-party audit reports prior to this event.
This surveil ance identified four Safety Findings and three Safety Observations. The Safety
Findings related to Insufficient Supervision, Training Management, Change Management
and Documentation Management. The discovery of further findings within this area, during
the current surveil ance event, indicates that the system used by the authorisation holder to
manage this element of the operation is stil not effective in eliminating findings of this
nature. It is expected the authorisation holder acts decisively to reduce the likelihood of a
recurrency; however repeat findings wil warrant further investigation by CASA.
The surveil ance team acknowledges the authorisation holder’s personnel for their
cooperation, assistance, openness and disposition during the surveil ance event.
Surveil ance Lead
08/08/2022
Form 1301 (11/2017)
Surveil ance Report
Page 2 of 22
TRIM REF:F18/2829-5
Surveil ance Event Number: 24241/ Report ID number: 36625
Sydney Departures West (SDW)
SDW was responsible for arriving and departing traffic into or out of YSBK. SDW also
processed Sydney departing traffic to the West and North-West.
Sydney Precision Approach Runway Monitor (PRM)
PRM endorsement qualified suitable rated staff to monitor independent parallel approaches
in IMC. This endorsement allowed the controller to issue breakout instructions to aircraft via
an override function over the associated Sydney Tower ADC frequency. PRM
endorsements were described in the ATS Licensing and Certificates Manual Appendix A.
SY TCU staff are not required to be a Fully Endorsed Controller (FEC) within Sydney TCU.
Training opportunities for the PRM endorsement was based on organisational requirements.
PRM was not being used at the time of surveil ance and evidence provided indicated that
there was no facility to continue PRM usage following the proposed move to Melbourne.
Sydney Director (SYF)
Sydney Director consisted of Sydney Director West (SFW) and Sydney Director East
(SFE). SYF was responsible for providing a surveil ance approach service to Sydney. The
function ensured an orderly flow of arriving traffic to parallel or single runways by providing
vectors and sequencing to final approach.
Sydney Planner (SPL)
SPL was responsible for all coordination with external units and was the conduit between
requests to enter Class C airspace and the appropriate controlling authority.
Sydney Flow (SFL)
SFL endorsement entitled the holder to tactically manage the Sydney Arrival Sequence.
Typically, this was be done prior to 150 NM Sydney.
Sydney Radar Information (SRI)
SRI endorsement provided a Flight Information Service in Class G airspace. SRI and SPL
generally operated as a combined position.
Sydney Traffic Manager (SYTM)
The Sydney Traffic Manager had overarching responsibility for service provision, airspace
management and staff management within the Sydney TCU as specified in local
instructions and in the National ATS Administration Manual. The Traffic Manager
endorsement did not contribute to FEC status and was trained for on a business needs
requirement. SYTM provided direct supervision at all times.
During daily periods of regular traffic, the Sydney TCU normally operated up to 13 control
positions consisting of Sydney Approach (North and South), Sydney Director (East and
West), Sydney Departures (North and South), Sydney Departures West, Sydney Approach
West, Sydney Radar Information, Sydney Planner, Sydney Flow and Sydney Precision
Runway Monitors (East and West).
During periods of light traffic, Sydney Approach normally combined with Sydney Director
and/or Sydney Flow. Sydney Departures normally combined with Sydney Departures
West, Sydney Approach West, Sydney Radar Information and Sydney Planner. During
single person operations (curfew hours) all positions were normally combined onto a single
console using the SOS endorsement. It was expressed on multiple occasions that the
SYTM position was considered a risk mitigator for the SOS endorsement not having
adequate knowledge of all the airspace.
Form 1301 (11/2017)
Surveil ance Report
Page 5 of 22
TRIM REF:F18/2829-5
Surveil ance Event Number: 24241/ Report ID number: 36625
Parallel runway operations
Sydney's closely spaced parallel runway operations were managed by SY TCU using a
combination of dependant and independent separation standards. In addition to the
standards for parallel operations outlined within ICAO DOC 4444, SY TCU utilised
Independent Visual Approaches (IVAs) as outlined within the Part 172 MOS para 10.4.5.
IVA's are a non-ICAO compliant procedure that permits SY TCU to conduct independent
operations during VMC without staffing the PRM position.
Independent Operations increased aerodrome capacity by reducing the required
separation standards provided either the final approach was monitored by a dedicated
controller (PRM) or during visual conditions (IVA).
At the time of surveil ance, independent operations (PRM) were not being conducted and
CASA was advised that PRM endorsements had expired due to lack of recency. Console
allocation following the proposed move to Melbourne also did not contain a provision for
PRM. This did not represent a safety concern as dependant operations may be used in
PRM absence. However, as traffic returns to normal, the absence of PRM can be expected
to negatively impact capacity at SY. This would be further exacerbated if CASA
discontinued the use of IVA in order to remove the difference from ICAO.
Sydney Long Term Operating Plan
The Airservices 2020-21 Annual Report Appendix A: Ministerial Expectations advised four
ministerial directions remained current, including the 1996 Handling of aircraft noise at
Sydney and other federal airports and the 1997 Progressive implementation of Sydney
Long Term Operating Plan (LTOP).
The LTOP included the following statements that remained relevant to SY TCU operations
and this report:
“The 1997 Ministerial Direction relating to the Sydney Long Term Operating Plan wil
continue to guide the operation of Sydney Airport.” “It is proposed that any additional risk imposed by runway changes be mitigated through
the enhancement of on-shift management of procedures and staff resources, focusing
authority and accountability of Air Traffic Services staff to a core position. Further
mitigation of risk will be achieved through improved planning to runway changes where
runway in use is not retained to a critical downwind criteria, necessitating short notice
changes. Further strategies wil be identified and documented during the implementation
process.” LTOP page 16 and 255 included obligations on AA for “…
close consultation with the Civil
Aviation Safety Authority…necessary to ensure…any new proposals for revised operating
arrangements…consistent with safety requirements.”
Personnel Rostering
Operational staff
As evidenced by SY TCU Group Status Report (GSR) and published rosters, staff
resources were barely adequate to ensure AA was able to meet their service provision
obligations. ANS Workforce Deployment Planning Procedure (C-PROC0289) v6 outlined a
system whereby a "mature" number was published that should ensure sufficient staff
Form 1301 (11/2017)
Surveil ance Report
Page 6 of 22
TRIM REF:F18/2829-5
Surveil ance Event Number: 24241/ Report ID number: 36625
Safety Observation
Authorisation holder: Airservices Australia
Issued Date: 08/08/2022
ARN:
202210
Safety
Observation No: 824503
Contact address:
GPO Box 367 CANBERRA ACT
Postcode:
2601
Subject/Title:
Mature Requirement did not ensure sufficient staff were available to
complete required tasks.
System:
Personnel
Element:
Personnel Rostering
Safety Observation Details: The calculated staffing requirements for SY TCU did not take into account endorsement mix and
consequently fell short of AA’s own requirement to provide sufficient staff to achieve:
• Operational shifts
• Breaks
• Recreation (and remote locality) leave
• Familiarisation
• Check and standardisation (admin time as well as recency, progress, simulator and final
training checks)
• Refresher training
• Mandatory enterprise training
• AA Enterprise Agreement
• Group Training Specialist Staffing
Continued staff management in this manner could potentially place AA to a breach of reg
172.110 of the CASR should the low levels of staff lead to AA being unable provide the service
listed on the Operator’s Certificate at all times.
Issuing Inspector Name:
A Safety Observation is a document used to advise an authorisation holder of:
• latent conditions resulting in system deficiencies that, while not constituting a breach, have the potential to
result in a breach if not addressed, and/or
• potential areas for improvement in safety performance
Form 1298 (11/2017)
Safety Observation
Page 13 of 22
Event Number: 24241
Safety Observation
Authorisation holder: Airservices Australia
Issued Date: 08/08/2022
ARN:
202210
Safety
Observation No: 824504
Contact address:
GPO Box 367 CANBERRA ACT
Postcode:
2601
Subject/Title:
Override facility as required by ICAO Doc 4444 (PANS ATM) Chapter
six ineffective.
System:
Air Traffic Service
Element:
Support Systems
Safety Observation Details:
The ADC frequency override facility provided as compliance with PANS ATM para 6.7.3.4.1,
whilst present, was not effective in providing an immediate response to a loss of separation.
In order to utilise the Dependant Parallel operations separation minima as defined in PANS
ATM, the controller monitoring the approach was required to be provided with an override facility.
The override facility provided at SY TCU was complicated and required significant time to use.
Controllers had been advised that it was faster to complete regular coordination as though the
override facility was not provided.
Additional y, the published procedure noted that a single button press was to be implemented at
a later date.
An Airservices review of the override facility would be an opportunity for improvement to
implement a system that provides more immediate intervention.
Issuing Inspector Name:
A Safety Observation is a document used to advise an authorisation holder of:
• latent conditions resulting in system deficiencies that, while not constituting a breach, have the potential to
result in a breach if not addressed, and/or
• potential areas for improvement in safety performance
Form 1298 (11/2017)
Safety Observation
Page 14 of 22
Event Number: 24241
Safety Observation
Authorisation holder: Airservices Australia
Issued Date: 08/08/2022
ARN:
202210
Safety
Observation No: 824505
Contact address:
GPO Box 367 CANBERRA ACT
Postcode:
2601
Subject/Title:
Risk assessment methodology
System:
Safety Management
Element:
Safety Risk Management
Safety Observation Details:
The SY TCU Operational Risk Assessment was incomplete and contained reference to hazards
that had not been present for a significant time.
An opportunity for improvement exists whereby an in-depth review of existing risks to service
provision at SY TCU to ensure continued safe provision of ATS be conducted.
Issuing Inspector Name: Aaron Betts
A Safety Observation is a document used to advise an authorisation holder of:
• latent conditions resulting in system deficiencies that, while not constituting a breach, have the potential to
result in a breach if not addressed, and/or
• potential areas for improvement in safety performance
Form 1298 (11/2017)
Safety Observation
Page 15 of 22
Event Number: 24241
Safety Finding
Authorisation
Holder:
Airservices Australia
Safety
ARN: 202210
EDRMS Ref: F18/2829-5
Finding Ref 728350
No:
Contact address:
GPO Box 367 CANBERRA ACT
Postcode:
2601
Regulatory
reference:
Reg 172.115 of the Civil Aviation Safety Regulations (1998)
Subject/Title:
Insufficient Supervisory Staff
System-Element:
Personnel - Personnel Rostering
Note: In applying the principles of procedural fairness, CASA approaches its regulatory functions in
a consultative and collaborative manner. Therefore CASA extends to the authorisation holder the
opportunity to consider, comment on or object to this Safety Finding.
It should also be noted that issue of a Safety Finding does not in any way prejudice CASA’s
prerogative to take at any time such regulatory or other legal action as may be appropriate in the
circumstances.
Details of deficiency:
Airservices Australia failed to provide enough suitably qualified and trained personnel who were
able to supervise the provision of air traffic services at SY TCU as required by Reg 172.115 to the
CASR.
SY TCU had insufficient staff to facilitate the direct supervisor requirement as published. This lack
of qualified personnel led to Air Traffic Services being provided without the published level of
supervision on at least six separate occasions.
Recent Safety Findings relating to 172.115 included:
• SF 727295 - 27/10/21- Under Enforcement action
• SF 725796 - 28/6/21 - Acquitted on 27/1/2022
Criteria: Reg 172.115 of CASR (1998) – Supervisory Personnel An ATS provider must have, at all times, enough suitably qualified and trained personnel who are
able to supervise the provision of any air traffic service that it provides.
Issuing inspector:
Date issued:
08/08/2022
Due date:
29/08/2022
Form 1299 (11/2017)
Safety Finding
Page 16 of 22
Event Number: 24241
Safety Finding
Authorisation
Holder:
Airservices Australia
Safety
ARN: 202210
EDRMS Ref: F18/2829-5
Finding Ref 728351
No:
Contact address:
GPO Box 367 CANBERRA ACT
Postcode:
2601
Regulatory
reference:
Reg 172.140 of the Civil Aviation Safety Regulations (1998)
Subject/Title:
Training not conducted in accordance with MOS
System-Element:
Personnel - Personnel Standards
Note: In applying the principles of procedural fairness, CASA approaches its regulatory functions in
a consultative and collaborative manner. Therefore CASA extends to the authorisation holder the
opportunity to consider, comment on or object to this Safety Finding.
It should also be noted that issue of a Safety Finding does not in any way prejudice CASA’s
prerogative to take at any time such regulatory or other legal action as may be appropriate in the
circumstances.
Details of deficiency:
Airservices Australia failed to provide, at all times, a training and checking program in accordance
with the Manual of Standard at SY TCU as required by Reg 172.140 to the CASR.
Two trainees conducted SYTM endorsement training without a published course or training needs
analysis (TNA) to define an ad-hoc course. Additionally, those same trainees were not provided a
Training agreement for SYTM training.
Recent Safety Findings relating to 172.140 included:
• SF 725825 - 16/7/21
• SF 725311 - 24/3/21
• SF 722817 - 8/10/19
• SF 722655 - 13/9/19
Criteria: Reg 172.140 of CASR (1998) – Training and Checking Program An ATS provider must, at all times, provide a training and checking program, in accordance with the
Manual of Standards, to ensure that each member of its personnel who performs functions in
connection with any air traffic service that it provides is competent to perform those functions.
Part 172 Manual of Standards 5.1.4.2 Training courses must be provided on the basis of a MOS Part 65 requirement, or training
needs analysis or similar method.
Form 1299 (11/2017)
Safety Finding
Page 17 of 22
Event Number: 24241
Safety Finding
5.1.4.3 The training programs for each course must be comprehensive and facilitate achievement
of training goals through a syl abus which reflects required competencies. The syl abus
must ensure compliance with relevant national and international requirements and CASA
competency-based training standards.
C-MAN0108 ATS Training Operations Manual v21, 3 Aug 2021 9.1.1 Individual Training Needs Analysis
A TNA for an individual is required when training for an endorsement for which familiarisation is not
deemed appropriate (i.e. the lapsed period of an endorsement is greater than six (6) months); and
either:
a. there is no approved published course
b. an approved course exists, and:
i. it is not to be delivered in its entirety (i.e. the course is being shortened to reflect RPL/RCC
for some components of the training program); or
ii. the course wil include additional training elements including significant changes (i.e.
technological, procedures).
9.3 A Training Agreement is a mechanism by which a trainee and Airservices can be assured of a
common understanding of:
• the training and assessment schedule as per the unit Training Manual or TNA (where
applicable)
• personnel involved in training and assessment
• roles and expectations of each participant in the agreement
• performance management options in response to unsuccessful training outcomes.
A Training Agreement is required for all endorsement training.
Issuing inspector:
Date issued:
08/08/2022
Due date:
29/08/2022
Form 1299 (11/2017)
Safety Finding
Page 18 of 22
Event Number: 24241
Safety Finding
Authorisation
Holder:
Airservices Australia
Safety
ARN: 202210
EDRMS Ref: F18/2829-5
Finding Ref 728352
No:
Contact address:
GPO Box 367 CANBERRA ACT
Postcode:
2601
Regulatory
reference:
Reg 172.160 of the Civil Aviation Safety Regulations (1998)
Subject/Title:
Reference documentation not maintained
System-Element:
Air Traffic Service - Data & Documents
Note: In applying the principles of procedural fairness, CASA approaches its regulatory functions in
a consultative and collaborative manner. Therefore CASA extends to the authorisation holder the
opportunity to consider, comment on or object to this Safety Finding.
It should also be noted that issue of a Safety Finding does not in any way prejudice CASA’s
prerogative to take at any time such regulatory or other legal action as may be appropriate in the
circumstances.
Details of deficiency:
Airservices failed to keep reference materials up to date and in a readily accessible form, as
required by Regulation 172.160(2) of the CASR (1998).
The following documents were found to contain out of date information, conflicting information, or
exceeded the review period specified in ATS Documentation Procedures (ATS-PROC-0039)
version 39.
• C-GUIDE0597 v5
• C-GUIDE0222 v9
• C-GUIDE0591 v3
• LoA_615 v4
• LoA_371 v27
• LoA_3131 v11
• ATS-PROC-0049 v103
• LoA_3181 v20
Recent Safety Findings relating to 172.160 included:
• SF 728104 – 3/6/2022
• SF 725821 – 16/7/2021
• SF 725801 – 28/6/2021
• SF 725439 – 20/4/2021
• SF 725382 – 6/4/2021
• SF 723797 – 7/9/2020
• SF 723794 – 27/7/2020
• SF 723793 – 27/7/2020
Form 1299 (11/2017)
Safety Finding
Page 19 of 22
Event Number: 24241
Safety Finding
Criteria: Reg 172.160 of CASR (1998) - Reference materials (2) The provider must keep the reference materials up to date and in a readily accessible form.
Issuing inspector:
Date issued:
08/08/2022
Due date:
29/08/2022
Form 1299 (11/2017)
Safety Finding
Page 20 of 22
Event Number: 24241
Safety Finding
Authorisation
Holder:
Airservices Australia
Safety
ARN: 202210
EDRMS Ref: F18/2829-5
Finding Ref 728353
No:
Contact address:
GPO Box 367 CANBERRA ACT
Postcode:
2601
Regulatory
reference:
Reg 172.145 of the Civil Aviation Safety Regulations (1998)
Subject/Title:
Change Management Procedure not followed - Traffic Manager
System-Elements: Safety Management - Safety Policy and Objectives and Safety Management
- Safety Risk Management
Note: In applying the principles of procedural fairness, CASA approaches its regulatory functions in
a consultative and collaborative manner. Therefore CASA extends to the authorisation holder the
opportunity to consider, comment on or object to this Safety Finding.
It should also be noted that issue of a Safety Finding does not in any way prejudice CASA’s
prerogative to take at any time such regulatory or other legal action as may be appropriate in the
circumstances.
Details of deficiency:
Airservices Australia failed to put into effect the safety management system policies, procedures,
and practices necessary at SY TCU as required by Reg 172.145 to the CASR.
Changes were planned to the SYTM position without CASA consultation.
AA’s Risk assessment policy and procedure as published in Airservices Risk Management
Standard (AA-NOS-RISK-0001) V12 required the risk assessment to include engagement and
consultation with appropriate stakeholders.
The Ministerial direction that lead to the creation of the SYTM endorsement stipulated a
requirement that changes to the SYTM role required consultation with CASA. Although CASA does
not regulate the ministerial direction, this inclusion confirms that CASA was a stakeholder for
proposed changes and should have been consulted under AA’s approved SMS.
Criteria: Part 172.145 of CASR (1998) – Safety Management System
(1) An ATS provider must have, and put into effect, a safety management system that includes the
policies, procedures, and practices necessary to provide the air traffic services covered by its
approval safely.
(2) The safety management system must be in accordance with the standards set out in the
Manual of Standards.
(3) The provider must keep under review its safety management system and take such corrective
action as is necessary to ensure that it operates properly.
Form 1299 (11/2017)
Safety Finding
Page 21 of 22
Event Number: 24241
Safety Finding
AA-NOS-RISK-0001
6.1 Mandatory risk management requirements. The following mandatory requirements detailed below must be applied by all Framework Owners
when designing risk management processes, as well as Airservices employees when applying a
risk management process:
…
6.1.3 Communication and consultation with appropriate internal and external stakeholders must
take place throughout all steps of the risk management process.
Issuing inspector:
Date issued:
08/08/2022
Due date:
29/08/2022
Form 1299 (11/2017)
Safety Finding
Page 22 of 22
Event Number: 24241
