Sydney ATC staffing under the microscope in ATSB probes

According to investigators, the four occurrences comprise:

• 27 July – a runway incursion where a Qantas Boeing 737 was cleared to cross in front of a QantasLink Dash 8 aircraft in its landing roll;
• 9 August – a taxiing proximity event where a Jetstar A320 braked abruptly to avoid a Qatar Airways Boeing 777 under tow. A flight attendant aboard the A320 fell during the braking and sustained a fractured wrist;
• 9 August – a runway incursion where a Qantas Boeing 737 was cleared to cross the runway in front of a Virgin 737 that had just been cleared for take-off; and
• 18 August – a taxiing conflict where a Qantas A321 had to brake to let a Qantas Boeing 737 pass in front of it.

“While air traffic control involvement in each occurrence is still being examined, we can say based on information detailed in our preliminary reports that staff resourcing within Sydney Tower at the time of many of the occurrences has emerged as a recurring area of enquiry,” said ATSB chief commissioner Angus Mitchell.

“These investigations will look to understand the significance of staff resourcing pressures within the tower, specifically, the practice of combining operational roles, the routine reliance on overtime to fill shifts, and training or supervision activities being conducted alongside operational duties.

“The ATSB does not investigate to apportion blame or liability. Our role is to independently examine the evidence, identify any systemic safety issues that may emerge, and bring them to light early and transparently so those best placed can consider whether any immediate and ongoing safety risks are being effectively managed.”

The ATSB also noted that “elevated fatigue risks for staff” had been predicted in Airservices’ roster modelling for many of the occurrences; the possibility of ATC fatigue has been raised in recent weeks as questions have been asked about scheduling in Sydney Tower.

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“It is important to note that an elevated fatigue risk in and of itself does not mean a controller was fatigued, or that fatigue influenced their performance. We are examining the effectiveness of the measures in place to manage this identified risk,” said Mitchell.

In its statistical report released alongside the preliminary investigation reports, the ATSB looked at whether 11 recent incidents at Sydney Airport in July and August “reflected a growing post-COVID trend, or a more localised pattern”.

“Nationally, over the decade, reported ground-confliction rates have remained broadly steady,” said Mitchell.

“However, Sydney recorded the highest confliction rate per aircraft movement post COVID among the major airports, around 20 per cent above the national average. This should however be viewed in the context of Sydney Airport being the most complex in the country.

“The analysis also found increases specific to Sydney in potentially high consequence occurrences, including runway incursions, taxiway near collisions and losses of separation attributed to air traffic control actions.”

In a press briefing, CASA representatives said the regulator “considers that Australia’s aviation system and Sydney Airport remain safe”, as noted in a communique by the Sydney Airport Air Traffic Control Working Group in August.

“Having reviewed the ATSB’s preliminary reports, CASA remains of the view that none of the incidents indicate an immediate safety risk. If safety action was needed, we would have taken it,” said CASA.

“While the ATSB continues its investigation and analysis, CASA is undertaking a safety assurance review focusing on whether there are underlying operational or system issues that could affect safety. CASA will not hesitate to act if broader safety issues are identified.

“Our focus remains on ensuring Australians can continue to have confidence in a safe, resilient and closely monitored aviation system.”

In response to concerns, Transport Minister Catherine King has also announced the establishment of the Sydney Airport Air Traffic Control Independent Assurance Panel, headed by retired Air Vice Marshal Ken Robinson AM.

“Australia has a well-earned reputation for aviation safety. These incidents and the ATSB’s preliminary reports highlight that we must take every opportunity to improve it,” the Minister said.

“Addressing operational and workforce challenges is critical to ensuring safe, reliable and resilient air traffic control services for the flying public.

“The Panel will provide independent assurance to Government that Airservices is implementing timely, enduring measures to improve service stability, reliability and resilience.

“The Panel will ensure Airservices is taking practical and timely action to address challenges including air traffic control workforce planning, recruitment, training, roster resilience and system improvements.”

In a statement, an Airservices spokesperson said the air navigation service provider will “review the interim reports and the findings once these investigations are complete”.

“Airservices Australia thanks the members of our team who have been cooperating fully with the Australian Transport Safety Bureau (ATSB) in recent weeks to support preparation of these interim reports,” the spokesperson said.

“We will continue to work with the ATSB on their investigations and we will work closely with CASA and the ATSB in regard to any improvements that can be applied. Safety remains our number one priority across the network.

“The aviation safety system is designed to manage operational risks through multiple safeguards and, based on the information currently available, the recent occurrences do not indicate an immediate safety risk to the travelling public.”

The news comes as Sydney Airport has also suffered highly publicised delays and disruptions, with Airservices figures showing ground delay minutes were almost 40 per cent higher than average at Kingsford Smith last month.