Occurrence types

Analysis of occurrence types showed that the most common accident and serious incident occurrences were turbulence, windshear, or microburst.

Diversion, return and missed approach, and go-arounds were also common. While the data shows these events occur more often than others, keep in mind the contributing factors. Some events will need further examination to determine the underlying causes.

Taxiing collisions and near collisions were the next most frequent occurrences.

Occurrence type level 3 of accidents and serious incidents (2014 to 2020)

Source: ATSB Occurrence data

Occurrence types – event risk classification

Analysing ATSB’s Event Risk Classification (ERC) for occurrences in the sector will help you gain further clarity on the sector risk.

ERC scores the potential risk in an occurrence. Analysis of these occurrences shows that the top 5 occurrence types with high and very-high risk potential were:

• loss of separation
• Airborne Collision Alert System warnings
• missed approach and, or go around (which is a consequential event)
• information and, or procedural error
• operational non-compliance.

Occurrence type level 3 for very high and high ERC (2014 to 2020)

Source: ATSB Occurrence data

Safety factors

ATSB applies safety factors to certain occurrences to identify underlying conditions or factors that contributed to the occurrence.

Approximately 15% of occurrences in the ATO-LA sector have safety factors assigned by ATSB.

The 5 most frequent safety factors for the sector between 2014 and 2020 were:

• mechanical discontinuity
• turbulence
• windshear
• electrical discontinuity
• monitoring and checking (aircraft operation action).

But when examining occurrences with an ERC of high or very high, the 5 most frequent safety factors were:

• visibility
• monitoring and checking (aircraft operation action)
• monitoring and checking (ATS action)
• procedures
• aircraft handling.

Safety factors overlay with their ERC High+ levels (2014-2020)

Source: ATSB Occurrence data

Strengths and opportunities

The safety performance data shows the sector has its challenges. But it also has several strengths, as identified in the SSRP workshop:

Opportunities

• Mentoring
• SMS education
• Data sharing. Alignment of data platforms
• Sharing 3rd party oversight between larger and smaller operators
• Developing / upcoming aircraft technology
• Larger operators educating smaller operators on risk management
• Remote airport technology
• Organisation expansion increases retention
• Industry support for aviation careers development
• Pathways into aviation from other industries
• Association promotion of aviation careers.

Strengths

• Existing safety experience resources
• Communication between operators and within organisations
• Depth of reporting within organisation
• External audits (other than CASA)
• Aircraft technology
• Well-defined sector with common purpose.