ASN Wikibase Occurrence # 310861
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Date: | Tuesday 8 November 2011 |
Time: | 14:00 |
Type: | Boeing 737-8FE (WL) |
Owner/operator: | Virgin Australia |
Registration: | VH-VUV |
MSN: | 37821/3288 |
Year of manufacture: | 2010 |
Fatalities: | Fatalities: 0 / Occupants: |
Aircraft damage: | None |
Category: | Serious incident |
Location: | abeam Ceduna Aerodrome, SA -
Australia
|
Phase: | En route |
Nature: | Passenger - Scheduled |
Departure airport: | Perth Airport, WA (PER/YPPH) |
Destination airport: | Melbourne International Airport, VIC (MEL/YMML) |
Investigating agency: | ATSB |
Confidence Rating: | Information verified through data from accident investigation authorities |
Narrative:What happened On 8 November 2011, a loss of separation occurred between a Boeing Company 737-8FE, registered VH-VUV, and a Boeing Company 737-838, registered VH-VXM, near Ceduna, South Australia. The aircraft were conducting scheduled passenger flights and were under the air traffic control of Airservices Australia (Airservices). The aircraft were operating on converging tracks at 39,000 ft. The procedural longitudinal separation standard of 20 NM (37 km) was infringed. It is likely that there was between 6 NM (11.1 km) and 12 NM (22.2 km) longitudinal separation between the aircraft. What the ATSB found The ATSB found that the two controllers involved were experiencing a high workload due to a range of factors, including the number of tasks and their limited experience. Airservices’ processes for monitoring and managing controller workloads did not ensure that newly-endorsed controllers had sufficient skills and techniques to manage the high workload situations to which they were exposed. In addition, Airservices’s fatigue risk management system (FRMS) did not effectively manage the fatigue risk associated with allocating additional duty periods. The ATSB is also concerned that there had been increasing traffic levels and complexity in some sectors in recent years, combined with a decrease in the experience levels of controllers and without a concomitant increase in controller resources. In addition, although Airservices has been in the process of developing and trialling a flight plan conflict function for procedurally-controlled aircraft for several years, the fact that it is still not operational is a safety issue.
Sources:
ATSB AO-2011-144
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