(1)  

(a)   Why is it not mandatory that planes, particularly charter flights carrying six or more passengers, be equipped with an approved terrain awareness and warning system;

(b)   Who made this decision and when; and

(c)   Is there a requirement for planes carrying more than six passengers in the United States to be so equipped.

(2)   In relation to the plane crash carrying five people near Benalla in 2004:

(a)   Was this plane equipped with an approved terrain awareness and warning system; if not, could the plane crash have been avoided with such equipment aboard; and

(b)   Did the Melbourne control tower receive (five times) an alarm triggered by the plane before it crashed; if so:

(i)   Why was the alarm not heeded,

(ii)   What response did the alarm evoke on each occasion,

(iii)   What action has been taken about the failure to heed the alarm, and

(iv)   What action has been taken to ensure such alarms are heeded in the future.

(1)  

(a)   Civil Aviation Safety Authority (CASA) requirements with regard to terrain awareness and warning systems are in line with the requirements outlined in International Civil Aviation Organization (ICAO) Annex 6 to the Convention on International Civil Aviation, Operation of Aircraft, which states: 6.15.1 All turbine-engined aeroplanes of a maximum certificated take-off mass in excess of 5,700 kg or authorised to carry more than nine passengers shall be equipped with a ground proximity warning system. And recommends the following: 6.15.6 Recommendation. - All turbine-engined aeroplanes of a maximum certificated take-off mass of 5,700kg or less and authorised to carry more than nine passengers shall be equipped with a ground proximity warning system which provides the warnings in 6.15.9(a) and (c), warning of unsafe terrain clearance and a forward looking terrain avoidance function.

(b)   See (1) (a).This requirement was first gazetted on 8 December 1982.

(c)   The United States Federal Aviation Administration requires all turbine-engined aeroplanes configured with six passenger seats to be equipped with terrain awareness and warning system (ground proximity warning system).

(2)  

(a)   No. However, the aircraft was equipped with a radio altimeter that indicated height above terrain directly below the aircraft that was capable of alerting the pilot at a pre-set height.

(b)   The air traffic control system at Melbourne Centre received three alerts in relation to deviations from the flight path of the aircraft involved in the accident at Benalla in July 2004. The alarms were of a type known as a Route Adherence Monitoring (RAM) alerts and are triggered when an aircraft within the coverage of radar deviates laterally by more than 7.5 nautical miles from the route clearance provided by air traffic control.

(i)   The first alert was responded to and appropriately actioned by a controller. The second and third alerts were acknowledged by a different controller while the aircraft was en route between the Moruya area and Benalla, who did not inform the pilot of the deviation as required by procedures. The Airservices Australia investigation team concluded that the controller did not provide the advice as required as they had knowledge of the pilot’s regular flights to Benalla and that the controller perceived the pilot to be highly professional. The controller therefore perceived that the pilot was effectively managing the navigation of the aircraft. This knowledge seemed to have led the controller to assume that the pilot of the aircraft knew where he was and what he was doing. The Australian Transport Safety Bureau (ATSB) investigation also reached the same conclusions.

(ii)   The first RAM alert presented to the Wollongong controller. Analysis of that controller’s actions shows that the alert was promptly acknowledged and prompted an exchange with the pilot concerning his tracking intentions. The controller’s actions were a valid reaction to receipt of a RAM alert in such a circumstance and had no further relevance on the flight. The second RAM alert occurred while the aircraft was being handed over from one sector controller to another while the aircraft was en route from the coast to Benalla. That alert was displayed on each of those controller’s air situation displays. Following the RAM alert, one controller assessed the track of the aircraft and did not notice anything unusual in that respect. The other controller also undertook a visual assessment of the aircraft’s track and determined that the aircraft was tracking as expected to the most northerly of the three waypoints at which the aircraft could commence an approach to Benalla. The pilot was not informed of the RAM alert. The third RAM alert occurred while the aircraft was on descent to commence an approach to Benalla from what appeared to be the most southerly waypoint available for the approach. The controller used on-screen tools to assess the track of the aircraft. This confirmed in his mind that the aircraft was heading towards the southerly waypoint and not the northern waypoint as previously understood. On this basis the controller took action that cancelled the RAM alert. The controller did not provide tracking advice to the pilot.

(iii)   Immediately following that accident, the controller oversighting the aircraft’s track at the time of the second and third RAM was removed from operational duty. The Controller has not been returned to operational duty. Airservices Australia promptly initiated a formal internal investigation in accordance with its safety management system requirements. The investigation made a number of recommendations that identified actions required that should reduce the likelihood of RAM alerts being un-heeded in the future. These recommendations were as follows: i. Training focused on existing and new controllers must be developed as a matter of priority that specifically addresses TAAATS alerts and alarms, and their management. ii. Information and training should be provided to controllers relating to the influence of human factors issues such as confirmation bias and processing of visual data. iii. Develop and implement a specific TAAATS graphic tool that readily displays on the air situation display an aircraft’s cleared route as recorded in the flight data record. iv. The Manual of Air Traffic Services (MATS), which provides procedural requirements for controllers, was reviewed to determine whether the relevant provisions relating to RAM alerts and general radar surveillance in circumstances where an aircraft deviates from cleared route, could be improved. v. Consider the inclusion in MATS of controller responsibilities in relation to the use of route (RTE) function and velocity vector specifically where these two functions are used simultaneously to determine track keeping. vi. Review the availability and knowledge of pilot track keeping requirements and deviations and consider inclusion of such information in annual rating papers. vii. In conjunction with the Civil Aviation Safety Authority (CASA), consider the development of specific phraseology to be used by pilots as they commence a Global Positioning System (GPS) Non-Precision Approach (NPA), such as that used Benalla, which includes notification of the waypoint at which the aircraft is located. The above recommendations were implemented, with the exception of recommendation vii which, after consultation with CASA, was rejected by Airservices Australia. In addition to the recommendations from the Airservices Australia internal investigation, the organisation undertook a review of ATC’s attitudes and response to alerts and alarms which concluded no systemic problem existed in relation to compliance with procedures relating to alerting pilots of track deviations. At the time of the accident, the organisation was upgrading its alert suite. This upgrade has now been implemented and aims to further enhance controller awareness and performance. The ATSB investigation report made no additional recommendations to Airservices Australia.