240411-Aura_QA-Loss_of_Separation_(Airprox)

• Site conducted

• Conducted on

  Date

• Prepared by

T - Conflicting Military and/or Non-radio Traffic

• Avoid active military route / areas

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E - Military Activity Areas

• Use of TCAS by Military

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• Military participation and compliance with Delta Ops Procedures

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• Conflicting civil traffic compliance with Delta Operators Procedures

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E - Lack of awareness of changes to Delta Ops

• Eastwind Aviation attends Delta Ops meetings

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• Delta Ops - Communication Plan

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• Flight Crew detects conflicting military aircraft through Visual Obs or RT SA

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E - Military Combat Operations

• VMC ops only

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• Safety Stand-down - All aircraft Land / RTB

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• Active transponder on conflicting 'non radio' traffic

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• Flight Crew detects incorrect position of other aircraft through TCAS derived SA

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T - Conflicting Commercial Traffic

• Positive Radar Identification (at LOS and DNPO (PH Int'l))

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• No Positive Radar Identification (Below 1500') (at Warri and other Delta areas)

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• Airworks Advisory Information - Southern Sector & Delta

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• Conflicting civil traffic compliance with Delta Operators Procedures

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E - Lack of awareness of changes to Delta Ops

• Eastwind Aviation attends Delta Ops meetings

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• Delta Ops - Communication Plan

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• Flight Crew detects conflicting aircraft through Visual Obs or RT SA

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• Flight Crew detects incorrect position of other aircraft through TCAS derived SA

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T - Loss of SA

• Flight Crew clear understanding of existing procedures in the area

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E - Lack of awareness of existing procedures

• Route / Area Line Training

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• Flight Crew adhere to sterile cockpit SOPs

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• Flight Crew have a correct shared mental picture via approach briefing

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E - Inappropriate use of automation

• FCOM / OEM Derived Automation Policy

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• Training in 'Use of Automation'

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• Conflicting civil traffic compliance with Delta Operators Procedures

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• Flight crew detects conflicting aircraft through Visual Obs or RT SA

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• Flight crew detects incorrect position of other aircraft through TCAS derived SA

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T - Incorrect or misunderstood ATC instructions

• ATC issuing understandable instructions using standard phraseology

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E - Comprehension and understanding

• Use and understanding of English

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• Routinely copying down key ATC instructions

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• Flight crew use of CRM to confirm shared mental picture

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• Flight Crew request clarification from ATC

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• ATC detecting and recognising an error during read-back

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• ATC/ Airworks/ HLO detecting and recognising conflicting traffic; which is not following advice.

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• Flt Crew maintains traffic SA and challenge ATC /HLO

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T - Flight Crew do not correctly manage aircraft to maintain clearance

• Flight Crew accurately enter clearance/ instructions into FMS/ instrumentation

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E - Flight Crew errors during data input

• Aircraft Systems - Design highlights errors/ differences

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• Flight Crew detect, recognise and correct error via crosscheck SOPs

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• Use of fully updated NAV data

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• Managing and Monitoring Flight Path

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E - Degraded flight crew monitoring due to complacency, distraction or fatigue

• Monitoring & Communications skills included in CRM

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• Flight & Duty Time Limitations

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• Fatigue Risk Management System (FRMS)

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• Adherence to SOPs that define monitoring roles and callouts

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• Flight Crew adherence to sterile cockpit SOPs

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E - Inappropriate manual handling of aircraft

• FCOM or OEM based automation policy for appropriate use of manual handling

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• ATC/ Airworks/ HLO detecting and recognising conflicting traffic; which is not following advice.

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T - Release of an Unairworthy Aircraft to Service

• See - Continuing Airworthiness / MCM - Release of an Unairworthy Aircraft to Service BowTie

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• See - Maintenance / AMO PM - Release of an Unairworthy Aircraft to Service BowTie

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Section Break - Top Event - Loss of Separation (Airprox)

C - Ineffective BowTie / HRM

• QA Mgnt System - Threat Line Audit

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C - Mid-air Collision

• HLO/ATC recognise the incursion and issues avoiding action

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• Flight Crew of both aircraft receiving TCAS RA

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• Flight Crew responds appropriately to instructions and/ or TCAS RA

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• Flight Crew of either aircraft detects and recognizes the conflict and takes emergency avoiding action

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C - Abrupt avoidance manoeuvre resulting in injuries

• Flight Crew responds appropriately to LoCI (above)

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• Aircraft protection systems limit certain manoeuvres (e.g.TQ_limiter)

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• Cabin secured for flight by SOPs

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• Cabin design features to minimise injuries (e.g FAK strapped down)

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