Ftcomply

CONTENTS
ABBREVIATIONS AND DEFINITIONS.......................................... v
EXECUTIVE SUMMARY .............................................................. vi
1. BACKGROUND......................................................................... 1
1.1 Bureau of Air Safety Investigation trend monitoring ....................1
1.2 Definition of Failure to Comply ....................................................1
1.3 Type of operation ........................................................................1
1.4 Failure to Comply incidents by location .......................................2
1.5 Failure to Comply incident trend at Sydney.................................2
1.6 Conclusion...................................................................................3
2. METHODOLOGY ...................................................................... 4
2.1 Scope ..........................................................................................4
3. OBJECTIVES ............................................................................ 5
4. FINDINGS AND DISCUSSION.................................................. 6

4.1 Type of operation ........................................................................6
4.2 Failure to Comply incidents by location .......................................7
4.3 Frequency of Failure to Comply Incidents ...................................7
4.4 STAR and SID design within Australia ........................................8
5. ANALYSIS OF SURVEY RESPONSES .................................... 9

5.1 Nature of Failure to Comply incident ...........................................9
5.2 Factors in Failure to Comply incidents ........................................9
5.3 Air Traffic Control instructions ...................................................11
5.4 Familiarity with procedure..........................................................12
5.5 Route briefing ............................................................................12
5.6 Charts and instrument plates ....................................................13
5.7 Equipment failure ......................................................................13
5.8 Potential improvements.............................................................14
6. CONCLUSIONS ...................................................................... 17
7. RECOMMENDATIONS ........................................................... 19
iii
APPENDIX 1 - INCIDENT REPORT FORM ................................ 20
APPENDIX 2 - SURVEY RESPONSES ...................................... 24

Question 1 .......................................................................................24
Question 2 .......................................................................................24
Question 3 .......................................................................................30
Question 4 .......................................................................................33
Question 5 .......................................................................................34
Question 6 .......................................................................................35
Question 7 .......................................................................................35
Question 8 .......................................................................................35
Question 9 .......................................................................................36
Question 10 .....................................................................................36
Question 11 & 11a...........................................................................37
Question 12 .....................................................................................38
Question 13 .....................................................................................38
Question 14 .....................................................................................40
Question 15 .....................................................................................40
Question 16 .....................................................................................40
APPENDIX 3 ............................................................................... 45
FURTHER TREND MONITORING..................................................45
iv
ABBREVIATIONS AND DEFINITIONS
ATC Air Traffic Control
ATS Air Traffic Services
BASI Bureau of Air Safety Investigation
CASA Civil Aviation Safety Authority
ESIR Electronic Safety Incident Report
FTC Failure to Comply

An air safety incident in which flight crew fail to follow an air traffic
clearance in controlled airspace.
HCRPT High-Capacity Regular Public Transport aircraft

An aircraft that is certified as having a maximum seating capacity
exceeding 38 seats or a maximum payload exceeding 4,200 kg.
ICAO International Civil Aviation Organisation
LCRPT Low Capacity Regular Pubic Transport aircraft

An aircraft that is certified as having a maximum seating capacity
not exceeding 38 seats or a maximum payload not exceeding
4,200 kg.
LNAV Lateral Navigation
NM Nautical Mile
MTOW Maximum Take-Off Weight
SID Standard Instrument Departure
SRD Standard Radar Departure
STAR Standard Arrival Route
VOR VHF Omni Range
v
EXECUTIVE SUMMARY
A Failure to Comply incident is defined as an air safety incident in which flight

crew fail to follow an ATS clearance in controlled airspace.
During 1994 BASI recorded an increase in the frequency of incidents

involving failures to comply with ATS clearances. This trend continued in
1995 and the largest increase appeared to be associated with the introduction
of new arrival and departure procedures at Sydney airport. The Bureau
conducted a preliminary study to confirm these trends and concluded that a
comprehensive study was necessary.
This report draws on data collected during the comprehensive study of

incidents in June, July and August of 1996. The primary data for this study
was received through ESIRs and questionnaires completed by the pilots of
aircraft involved in FTC incidents.
The data collected showed that 35% of all incidents involved HCRPT aircraft.
Private aircraft recorded the next highest proportion of 29%. The incidents
involving high capacity aircraft are the focus of this report.
The results of the study confirm the preliminary findings that operations at
Sydney airport have the highest level of FTC incidents amongst Australia’s
major airports. Arrival and departure procedures contributed the majority of
incidents in Sydney, continuing the trends identified in the preliminary report.
The underlying factors in FTC incidents are:
• communication (of particular concern with foreign flight crews);
• ATC procedures;
• SID and STAR design; and
• aircraft operating procedures.
vi
1. BACKGROUND
1.1 Bureau of Air Safety Investigation trend monitoring
The Bureau of Air Safety Investigation maintains a computer database of

reported incidents and accidents which enables the Bureau to monitor trends.
This study was initiated in response to an upward trend in FTC incidents
which began in 1994 and continued throughout 1995. A preliminary study
was conducted in order to examine the pattern of FTC incidents in Australia
and to provide background information in advance of the more detailed BASI
study described later in this report.
1.2 Definition of Failure to Comply
A Failure to Comply (FTC) incident is defined as an air safety incident in

which flight crew fail to follow an ATS clearance in controlled airspace.
1.3 Type of operation
Figure 1 indicates that the majority of FTC incidents in the 2-year period
involved HCRPT aircraft. FTC incidents during flying training increased in the
same period although the total number in this type of operation remains
relatively small.
FIGURE 1
Reported Failure to Comply incidents by statistical grouping, 1994–1995
Other Aerial Work
Military
Private
Business
Flying Training
Commercial Charter
Low Capacity
High Capacity
0 20 40 60 80 100 120 140 160
Number of Incidents
1994 1995
1
1.4 Failure to Comply incidents by location
During 1994 and 1995, Sydney ATS reported the largest number of FTC
incidents (65%) involving aircraft over 5,700 kg MTOW. Melbourne, Perth,
Cairns and Brisbane had the next highest numbers of occurrences. Table 1
compares the frequency of FTC incidents between Sydney and other cities.
TABLE 1
Frequency of Failure to Comply incidents involving
aircraft > 5,700 kg MTOW (1994 and 1995) by location
Location 1994 1995
Sydney 63 97
Perth 8 9
Melbourne 4 15
Cairns 8 6
Brisbane 7 4
Other 11 16
1.5 Failure to Comply incident trend at Sydney
Figure 2 presents the number of FTC incidents at Sydney, involving aircraft

over 5,700 kg, by month for 1994 and 1995. There were significant increases
in July 1994, December 1994, February 1995, and November 1995.
FIGURE 2
Failure to Comply incidents at Sydney involving aircraft > 5,700 kg
MTOW, 1994–1995
STARs Introduced
18 18 New SIDs
17
16 New Charts
Parallel Runway 15
14 14
13 13
12
11
10 10
9
8 8
7
6 6 6
4 4 4
3 3
2 2
1
0 0 0 0 0 0
Jun
Jun
Jul
Jul
Sep
Dec
Sep
Dec
Jan
Jan
May
Mar
Nov
May
Mar
Nov
Oct
Oct
Feb
Aug
Feb
Aug
Apr
Apr
1994 - 1995
2
These increases in incidents coincided with the major changes in procedures
outlined below:
June 1994 The former Civil Aviation Authority introduced STARs to

Australia. STARs were introduced at Sydney and Melbourne
followed by progressive implementation at other major ATS
locations.
Nov. 1994 Opening of parallel runway (16L/34R) at Sydney airport.
Feb. 1995 New SIDs introduced at Sydney airport.
Nov. 1995 New charts were issued regarding ATS procedures including
STARs and SIDs.
1.6 Conclusion
The analysis of incidents for the 2-year period 1994 to 1995 indicates that
FTC incidents increased in frequency from July 1994. The largest number of
incidents were associated with Sydney operations and involved high-capacity
civil aircraft, although FTC incidents were also reported in Melbourne, Perth,
Cairns and Brisbane.
The findings of this preliminary work indicated a need for a further in-depth
study and analysis of FTC incidents. The following section presents the
findings of that study.
3
2. METHODOLOGY
All FTC incidents in the period June to August 1996 were examined. Basic
descriptive data were obtained from the ESIRs submitted to BASI by
Airservices Australia. A specifically designed survey form was then sent to
pilots of regular public transport and charter operations, and pilots from the
business/private and training operations, involved in selected FTC incidents.
This provided more detailed information on the circumstances of the incident.
Where necessary, automatic voice logging recorder tapes were replayed and
analysed.
2.1 Scope
Basic descriptive data was gathered on FTC incidents which occurred within
Australian airspace during June, July and August 1996.
This report presents information gained through the ESIR system and
subsequent detailed incident reports.
This report includes information relating to operations involving fare paying

passengers (Regular Public Transport and Charter), business flying, flying
training and private flying.
4
3. OBJECTIVES
The objectives of this study were to:
(a) identify trends of FTC incidents in Australia;
(b) analyse FTC incidents to identify common factors;
(c) identify potential solutions to the FTC problem; and
(d) make recommendations as appropriate.
5
4. FINDINGS AND DISCUSSION
During the period June to August 1996, the Bureau received 120 ESIRs of
FTC incidents. Forty-eight survey forms were sent to pilots in this period and
40 survey forms were completed and returned. This represents an 83%
response rate.
The following information relates to the information received through the

ESIRs in June, July and August 1996.
4.1 Type of operation
Figure 3 indicates that HCRPT aircraft were involved in 42 FTC incidents in

the period June to August 1996, more than any other statistical group.
HCRPT aircraft accounted for 35% of all FTC incidents, of which foreign high-
capacity operators represented 87%.
Private aircraft contributed 29% of the recorded FTC incidents and flying
training incidents continued to occur in significant numbers.
FIGURE 3
Reported Failure to Comply incidents by statistical grouping, June–
August 1996
Other Aerial Work 1
Military 4
Helicopter 3
Private 35
Business 7
Flying Training 13
Commercial Charter 9
LCRPT - Freight 1
LCRPT - Australian 4
HCRPT - Foreign Freight 1
HCRPT - Foreign 34
HCRPT - Australian 7
0 5 10 15 20 25 30 35
Number of Incidents
6
4.2 Failure to Comply incidents by location
Figure 4 shows FTC incidents for all aircraft and illustrates that the pattern
shown in table 1 is continuing, with Sydney ATS reporting the largest number
of FTC incidents for the 3-month period.
FIGURE 4
Reported Failure to Comply incidents by airport, June–August 1996
35
30
25
Number of Incidents
20
All Other HC RPT

15
10
0
Canberra
Sydney
Coffs Harbour
Perth
Maroochydore
Melbourne
Cairns
Brisbane
Albury
Archerfield
Bankstown
Darwin
Essendon
Rockhampton
Jandakot
Parafield
Moorabbin
Coolangatta
Williamtown
Adelaide
Townsville
Figure 4 shows the major airports at which incidents associated with high-
capacity aircraft are occurring. Sixty-seven per cent of all the reported HCRPT
incidents in the 3-month period occurred at Sydney (28 FTC incidents), with
the next highest, 12%, occurring at Melbourne.
4.3 Frequency of Failure to Comply Incidents
Table 2 shows the frequency of FTC incidents in relation to total aircraft

movements at major Australian airports. As can be seen, Sydney not only
recorded the greatest number of these incidents, but also experienced the
highest rate of such incidents per 10,000 aircraft movements.
7
TABLE 2
Frequency of Failure to Comply incidents, June–August 1996
Airport Incidents1 Total FTC / 10,000
movements2 movements3
Sydney 34 94,266 3.61
Perth 9 26,543 3.39
Cairns 6 30,839 1.95
Melbourne 10 58,508 1.71
Adelaide 4 33,082 1.21
Brisbane 6 54,656 1.10
TOTAL 69 297,894 2.32
1. Incidents = all reported FTC incidents, including both high capacity and other aircraft.
2. Total movements = total arrivals + total departures for June, July and August 1996.
3. This figure shows the number of FTC incidents reported for every 10,000 movements at
each of the listed airports.
4.4 STAR and SID design within Australia
The development of STAR and SID procedures was reviewed.
STARs were introduced to Australia in June 1994. STARs and SIDs within
Australia are designed in accordance with the ICAO obstacle clearance
standards by CASA in conjunction with Airservices Australia. No other set of
consistent standards is applied and as a result, certain inconsistencies exist
in STAR and SID design within Australia.
• Some current ATC procedures relating to STARs do not follow accepted

worldwide practice. Generally, worldwide practice is to issue a STAR that
leads the aircraft to a position from which an instrument approach can be
made. However, in Australia this is not always the case. STARs at
Melbourne generally position the aircraft to join an instrument approach,
whereas Sydney, Brisbane and Perth STARs culminate with the
expectation of radar vectoring to join the final approach course.
Furthermore, in Australia STARs may be cancelled and then resumed,
which is not accepted international practice.
• It would appear that for traffic flow management, ATC employs the practice
of vectoring an aircraft off a STAR, followed by an instruction to resume the
STAR. This appears to limit the effectiveness of the STAR procedure.
• Compared with accepted worldwide practice, many Australian STAR

procedures include a lengthy ‘transition’ leg. Confusion exists amongst
some air traffic controllers as to whether the transition forms part of the
STAR, and therefore which ATC rules apply to the processing of aircraft
during this phase of flight.
8
5. ANALYSIS OF SURVEY RESPONSES
Responses to the Incident Report Form were a major source of information

for this study. Unedited extracts from 11 of these appear in this report (see
below). The responses provided information on the factors contributing to
FTC incidents and suggestions to prevent further incidents. The results of the
survey are presented below.
5.1 Nature of Failure to Comply incident
In the survey, the pilots were asked to categorise their incident into one of
seven phases of flight. Figure 5 illustrates their responses, showing that the
greatest number of reported FTC incidents occurred while flying a STAR.
These accounted for 40% of all FTC incidents during this period.
FIGURE 5
Reported Failure to Comply incidents by flight phase, June–August 1996
Standard Instrument
Enroute Departure
Standard Radar
8% 15%
Departure
13%
Departure
(other)
3%
Arrival
(other)
7%
Climb
14% Standard Arrival
Route
40%
5.2 Factors in Failure to Comply incidents
The pilots were asked to provide an account of why their incident occurred.
The reasons given can be grouped into the following categories:
• Misunderstanding of ATC instructions. This was due to language

difficulties between ATC and the pilot, and also the use by ATC of
abbreviations and terminology with which pilots were unfamiliar. Example
1 illustrates the type of difficulty experienced by some foreign crews.
9
EXAMPLE 1
Pilot report ref. ADE_00071
The aircraft’s clearance was amended due to military action at Woomera.
The pilot failed to fly from Ardrossan direct to Ayers Rock as instructed and
instead continued to track as originally cleared, heading the aircraft towards
Woomera.
‘I’ve misunderstanding about clearance “ADE-AR-AYERS ROCK”. Because

there is no word “DIRECT” on this clearance [from “AR” to “AYERS ROCK”]
that mean I have to fly follow the airways [AR–WOOMERA–AYERS ROCK]...I
have difficulty about pronounce & slang.’
• Pilot distraction. Pilots were distracted by a number of factors, including

passengers, weather, ATC communications, preoccupation with aircraft
serviceability, and engine management.
• Lack of concentration/attention by pilots and crew. Several pilots

mentioned their lack of attention, with particular emphasis on attention to
altitude requirements. Example 2 illustrates how one crew was distracted
by en-route weather conditions, causing non-compliance with ATC
instructions.
EXAMPLE 2
Pilot report ref. SYA_01113
The aircraft was issued with a JET 4 departure which requires the aircraft to
turn right at 800 ft and intercept and track by the 163 radial. However, the
aircraft turned left to intercept the 102 radial.
‘The crew was very concerned about the weather conditions for takeoff and
departure. We actually had a loss of airspeed during takeoff, and turbulence
was encountered once airborne. These facts took away some of our
attention from the SID.’
• Flight Management System input errors, as illustrated in example 3.
EXAMPLE 3
Aircraft was given route YSSY RIC NYN; however, the aircraft incorrectly
attempted to track YSSY RIC MDG NYN.
‘Checking of the FMGS data routing was inadvertently skipped and we flew
on the wrong data routing to MDG.’
• Failure to confirm instructions. Generally, this problem arose where

clearances were amended and the operational status of the prevailing
procedure was not confirmed.
10
5.3 Air Traffic Control instructions
Throughout the survey responses, pilots reported various problems with the
delivery and confirmation of ATC instructions. Several pilots commented on
the potentially dangerous practice of assuming ATC’s intentions without
seeking confirmation. Example 4 illustrates how a false assumption on the
part of the aircrew can lead to an FTC incident.
EXAMPLE 4
Pilot report ref. SYE_00029
The aircraft failed to comply with the vertical requirement of the LETTI 3
arrival at YANGO.
‘I understood that altitude restriction of “YANGO” is cancelled by instruction to

descend to 10,000 ft.’
Table 3 indicates that of the 38 incidents where information is available, the

original clearance or instruction was cancelled or modified in 17 cases (or
45%). In 1992, the Ratner review of Air Traffic services recommended that air
traffic management in Australia be standardised, even if this resulted in a loss
of ‘personalised’ service to pilots. The implementation of this recommendation
could be achieved in part by ‘running the system on rails’ with the use of
STARs and SIDs. The limited data presented in table 3 suggests that
Airservices Australia has not yet fully embraced the concept of standardised
procedures as advocated in the Ratner review.
TABLE 3
‘Was the original clearance/instruction modified in any way or
cancelled?’
Yes No No answer
SID 2 4 0
STAR 9 5 2
Climb 1 5 0
Arrival (other) 2 1 0
Departure (other) 1 0 0
SRD 2 3 0
En route 0 3 0
Descent 0 0 0
17 21 2
Analysis of data relating to BASI’s preliminary study of advanced-technology

aircraft supports the above figures. Pilots have mentioned several cases of
Sydney ATC taking aircraft off the RIVET 3 ARRIVAL and placing them on
the OAKDALE 2 ARRIVAL. Instructions such as these cause many pilots to
feel that ATC, and Sydney ATC in particular, do not fully appreciate the
capabilities and limitations of automated aircraft. Pilots are concerned that
ATC are unaware of the amount of time required to reprogram the FMC
whenever a major change in clearance is given. Further evidence of ATC’s
11
lack of appreciation of FMC capabilities are the frequent instructions for pilots
to simultaneously reduce speed and descend, a procedure with which it is
difficult to comply.
The study also shows that pilots are not satisfied with the delayed assignment
of runways at Sydney and that frequently a change of assigned runway is
given within 20 NM. Pilots prefer to know the runway assignment as early as
possible, ideally before they commence descent, and where possible before
reaching 50 NM from the airfield. This reduces the need for further FMC
programming or manual intervention by the pilot, and consequently reduces
cockpit workload at the one of the busiest stages of the flight.
The FTC study reveals three incidents where the pilots of automated aircraft
had pre-programmed the FMS in anticipation of an airways clearance. This
practice of pre-programming an expected clearance allows the best possible
top of descent point and subsequent descent profile. On these three
occasions the aircraft followed the programmed route contrary to ATC
instructions, as illustrated in example 5.
EXAMPLE 5
Aircraft was inbound to Sydney on the RIVET STAR and at TAMMI
commenced a right turn of about 60 degrees instead of continuing to the
VOR.
‘It would be helpful if it was made clear at what point the STAR would be
cancelled on favour of radar vectors, i.e. “Expect radar vectors after TAMMI”.’
5.4 Familiarity with procedure
The majority (67.5%) of respondents had previously carried out the particular
procedure, and all pilots had flown to the destination on at least one other
occasion. Furthermore, 75% of pilots stated that they had flown to the
destination at least three times in the previous year.
Ninety-two per cent of HCRPT crews fly a SID on most or all flights, while
81% of crews fly a STAR on most or all flights.
5.5 Route briefing
An accurate route briefing should prepare the flight crew for potential
contingencies en route. Twenty-five per cent of crews did not refer to any
route briefing material prior to the flight.
Of the pilots carrying out the procedure for the first time, 46% did not refer to
a route briefing. Furthermore, one respondent who was flying the procedure
for the first time and did receive a route briefing, felt that the material referred
to was not adequate. Similarly, 28% of the pilots who referred to a route
12
briefing felt that it did not adequately prepare them for the ATC instructions
received during the flight within Australian airspace.
5.6 Charts and instrument plates
All respondents were using charts and instrument plates appropriate for the
procedure being undertaken. In all but one HCRPT incident, Jeppesen charts
were used. In the one other incident of this nature, Aerad charts were used.
In contrast, Jeppesen charts were used in approximately one-half of the non-
HCRPT incidents, with Airservices Australia charts being used in the
remaining incidents of this nature.
Two respondents claimed to have had problems with the procedures or

charts, which made it difficult to comply with ATC requirements. In both of
these incidents, Jeppesen charts were used. In each case, ATC gave
clearance to an altitude lower than that specified in the charts. As a result,
the pilots incorrectly assumed the altitude restrictions of the STAR were
overridden by the ATC instructions.
Example 6 illustrates the potential for misunderstanding between ATC and

aircrews.
EXAMPLE 6
The aircraft was cleared by a RIVET 3 ARRIVAL to Sydney. The STAR
states that the aircraft will reach 8,000 ft by TAMMI. The aircraft was given a
clearance to 7,000 ft and then later an amendment was given to maintain
10,000 ft. Clearance was then given to 6,000 ft. At TAMMI the aircraft was
on descent through 9,500 ft.
‘The changes in descent levels without clarification after the amended

maintain 10,000 ft and the later clearance to 6,000 ft that we were still
required to be at 8,000 ft over TAMMI.’
However, the correct wording of Jeppesen Airways Manual 10-2G states that
aircraft will be ‘at or below 8,000 ft’ at TAMMI.
Similarly, the pilot involved in example 4 believes that there is the possibility
of a misunderstanding when a lower altitude clearance than that specified in
the STAR is given. Upon receiving the clearance, the pilot states that he
‘might consider the [alt] restriction is cancelled’.
5.7 Equipment failure
Equipment failure was reported to have occurred in four incidents. Of these,

two were non-high capacity incidents where it was reported that the VHF 1
communication failed and was remedied by switching channels. In three of
the four cases, the failure contributed to the incident. Example 7 illustrates
how equipment failure can contribute to an FTC incident.
13
EXAMPLE 7
Due to several flight level changes and the failure of the autopilot to level off,
the pilot’s attention was diverted from the requirements of the STAR and the
pilot subsequently failed to turn the aircraft right as required.
‘Autopilot failed to level off as desired (could be due to high descent rate). A/c
went through FL190. The failing was discovered about 200 ft below FL190 by
the pilot. Pilot took over control manually.’
5.8 Potential improvements
The survey provided pilots with the opportunity to suggest improvements

which might prevent the incident occurring in the future. These suggestions
fall into two groups:
Air Traffic Control improvements
• ATC should clarify all amendments. Pilots believe that a

confirmation of continuation, or cancellation, of a procedure should
be made at each amendment. This is particularly relevant where
altitude restrictions may be involved. This action may reduce the
confusion associated with amendments to STARs, as illustrated by
example 6.
• ATC should be more aware of the capabilities of FMC aircraft and

provide instructions that reflect these capabilities.
• Regular cross-checking of altitude and location should be

conducted between ATC and the pilot. This should facilitate the
earliest possible detection of potential errors.
• Information relayed to the flight crew should be simpler and

clearer. (This suggestion was made by many of the international
crews.)
• Information should be timely. Firstly, any information to crews

should be provided early enough for the crew to respond
appropriately; and secondly, where an incident has occurred, ATC
should respond quickly to limit that incident, using regular cross-
checks as outlined above.
Pilot/crew improvements
• Flight crew should increase their concentration. Several pilots felt

that an increase in their concentration level would help avoid future
incidents, as illustrated in example 8.
14
EXAMPLE 8
Pilot report ref. MLE_00389
WHAT CHANGES COULD BE MADE TO PREVENT THIS INCIDENT
HAPPENING IN THE FUTURE?
‘More diligence on behalf of pilot.’
• Flight crew should give greater attention to autoflight data input.

Several pilots suggested that flight plans are not checked properly.
Regular cross-checks with ATC on actual position should be
referenced against autoflight data to ensure that the correct route
is being flown, as illustrated in example 9.
EXAMPLE 9
‘Ensure that inserted inbound routes are complying with instructions when
using LNAV and autoflight system.’
• Flight crew should obtain correct and complete information. Some

pilots commented that further pre-flight briefing would have assisted
in avoiding the incident. Additionally, several pilots felt that they
should have obtained further clarification from ATC especially with
regard to operational status of STARs and SIDs following
amendments to their original clearance, as illustrated in example 10.
EXAMPLE 10
Pilot report ref. SYA-01089
All Sydney arrivals and departures were operating on RW 16L and 16R. The
aircraft was given a SID departure for RW 34L from Sydney. Therefore, the
SID was inappropriate. The pilot assumed that the information received was
correct, but should have realised that it was inappropriate for that runway.
‘I was aware that a WMD7 SID was not apparently applicable to R/W 16R
(confirmed by FMS database and Aerad SID book) but incorrectly assumed
that as no change of instruction had been given by either Delivery, Ground or
Tower Controllers, the routing was the desired one.’

‘A) As an aircraft commander, to ask for qualification of any Air Traffic Control
clearance that has ambiguity or potential for error or misunderstanding.
B) If prevailing conditions change a clearance status, then it is also incumbent
on any Air Traffic Control unit to make sure an aircraft has a correct and
appropriate Air Traffic Control airways clearance.’
15
Other suggestions
• One suggestion called for the introduction of altitude alert lights on

light aircraft. The absence of an alerting system contributed to an
incident where, due to the pilot carrying out engine management
tasks, monitoring of altitude was overlooked and a subsequent
altitude bust occurred. Example 11 highlights one of the difficulties
faced in single-pilot IFR operations.
EXAMPLE 11
‘One thing that is lacking in most light aircraft is that the assigned altitude
indicators do not have altitude alert. I think if these where fitted then if
altitudes were exceeded it would be only by 200 ft as there are times in the
single pilot IFR environment that the pilot can be busy with a low altitude
restriction.’
16
6. CONCLUSIONS
Failure to comply incidents have been analysed through the use of the
Incident Report Form questionnaire which has provided a valuable source of
information. The questionnaire has been instrumental in ascertaining pilots’
views not only on the incident, but also on potential improvements.
The findings of this study confirm the trends identified in the preliminary
study. The overall rate of incidents based on total movements is small.
However, the incident rate at Sydney is of concern as on average there were
two incidents per week involving HCRPT aircraft. Therefore, it is important
that the underlying factors responsible for the incidents be identified and
steps taken to address them.
Many of the incidents involved altitude requirements of STARs. In general,

the problem arose when ATC issued altitude amendments but no
confirmation of the continuation, or cancellation, of the STAR was given. It
appears that some air traffic controllers assume that the pilots are aware of
the operational status of the STAR, when on some occasions this has not
been the case. Equally, pilots have misinterpreted ATC’s altitude clearances,
resulting in the assumption that STARs are no longer active. This has also
caused failures to comply where pilots have incorrectly ceased the STAR and
have expected vectors for the approach. Additional information gathered
from a preliminary study of automated technology aircraft supports this
analysis. In that study, several pilots commented that once a STAR is
cancelled it should not be resumed. Furthermore, examples were given
where aircraft were taken off a STAR and placed on a different STAR,
causing aircraft to miss the altitude restrictions of the later STAR. It was also
noted that STAR design was not consistent at all locations. Many STARs
culminate with the expectation of radar vectoring to final approach where
others position the aircraft to join an instrument approach.
The results of this study suggest that Airservices Australia has yet to fully
embrace the concept of standardised traffic management procedures
advocated in the Ratner review of 1992. Although standardised approach and
departure procedures have been introduced since the review, the benefits of
this standardisation may be lost if controllers regularly modify or interrupt
these procedures.
Similar problems exist with SID procedures. Incidents have occurred in

Sydney involving aircraft flying the incorrect SID for the particular runway,
resulting in the aircraft turning toward the incorrect VOR radial. Two FTC
incidents occurred when aircraft operating a SID were given an amended
clearance, causing the pilot to assume the SID was no longer applicable.
Again it appears that communication between ATC and the pilot is a
contributing factor to these FTC incidents.
The charts and instrument plates do not seem to be an area of concern, as

only 5% of respondents claimed to have any problems with them. While the
17
proportion of Jeppesen charts used during these incidents was high, it should
be remembered that almost all aircraft movements at Australia’s major
airports using these charts are conducted without incident. Similarly, failure
of aircraft equipment was not a significant factor in FTC incidents.
On an airport-by-airport basis, Sydney has maintained its relatively high level

of reported FTC incidents. Of continuing concern is the rate of error
regarding SIDs and STARs. In the first 5 months of 1994, there was only one
FTC incident at Sydney airport. With the introduction of STARs and SIDs in
1994 and 1995 respectively, FTC incidents rose significantly. Since that time,
the number of FTC incidents has remained on average at over 10 per month.
The majority of these incidents resulted from misunderstanding ATC
instructions for altitude amendments. A solution to this problem was
suggested by several flight crew. They feel that confirmation of altitude
requirements and the operational status of STARs should be given whenever
an altitude amendment is made. The pilots believe this will alleviate the
confusion surrounding the operational status of the altitude requirements of
STARs and SIDs.
Pilots indicated that the responsibility for FTC incidents can be apportioned
between themselves and ATC. It is clear that the majority of the pilots believe
the main area of concern is lack of communication. Improvements are
required from both ATC and pilots to correct this problem. All pilots, and
foreign pilots especially, require ATC instructions to be clear and simple, and
where possible, to be free from unfamiliar abbreviations and terminology. It
may also be necessary to increase the number of cross-checks, particularly
when altitude amendments have been made.
Since the end of the 3-month study period, the Bureau has used the ESIR
system to continue monitoring FTC incidents in Australia. Appendix 3 shows
that the trends identified in this study are continuing. It appears that these
trends will continue until measures are taken to address the situation.
18
7. RECOMMENDATIONS
As a result of this study the Bureau of Air Safety Investigation issues the
following recommendations:
R970010
The Bureau of Air Safety Investigation recommends that Airservices Australia:
1. Review the current methods of flow control management with the aim of
minimising the need for vectoring aircraft within the STAR environment.
2. Minimise the practice of instructing aircraft to resume a STAR once

vectored off the STAR.
3. Ensure that SIDs and STARs, at all locations, are developed in accordance
with consistent design principles.
4. Maximise the use of ICAO standard radio phraseology in accordance with

accepted worldwide practice.
5. Ensure that STAR design is compatible with aircraft FMS programs,

especially for STARs which are not runway specific.
R970011
The Bureau of Air Safety Investigation recommends that the Civil Aviation
Safety Authority require all international RPT AOC holders to include
comprehensive route briefings in their General Operations Manual and
require their aircrew to review comprehensive route briefing material prior to
each flight to Australia.
19
APPENDIX 1 - INCIDENT REPORT FORM
INCIDENT REPORT FORM (FTC060896)
IMPORTANT - PLEASE COMPLETE THIS FORM AND RETURN IT TO

BASI WITHIN 48 HOURS
Details of the pilot in command.

Name.................................................. Telephone Number (Day)...........................
Address.............................................. Telephone Number (Night).........................
........................................................... Fax Number...............................................
........................................................... Email address............................................
Details of the pilot flying.

Rank...................................................
Name.................................................. Telephone Number (Day)...........................
Address.............................................. Telephone Number (Night).........................
........................................................... Fax Number...............................................
........................................................... Email address............................................
a. Read all questions carefully.

b. TICK the appropriate response. eg
c. Where written information is required, please write your answer within the space provided.
d. You may respond by ticking MORE than one box.
1. This incident happened while flying,
a SID (Standard Instrument Departure a SRD (Standard Radar Departure)

a STAR (Standard Arrival Route ) Enroute
Climb Descent
Arrival other (Please specify)...........................................................................................
Departure other (Please specify)......................................................................................
2. Please describe what happened. Try to give as much detail as you can.
......................................................................................................................................................
......................................................................................................................................................
......................................................................................................................................................
..............................................................................................................................
20
3. In your opinion, WHY did the incident happen?
......................................................................................................................................................
......................................................................................................................................................
......................................................................................................................................................
......................................................................................................................................................
......................................................................................................................................................
..................................................................................................................
4. Which of the following were engaged/disengaged at the time of the incident? Please tick.
Engaged Disengaged
Auto Pilot
Auto Throttle
Flight Director System
VNAV
LNAV
5. Did you have any difficulty understanding the air traffic controller’s instruction?
Yes No
If Yes, please explain further
......................................................................................................................................................
......................................................................................................................................................
......................................................................................................................................................
......................................................................................................................................................
......................................................................................................................................................
..................................................................................................................
6. What charts or instrument procedure plates were being used at the time of the incident?
......................................................................................................................................................
......................................................................................................................................................
......................................................................................................................................................
..............................................................................................................................
7. Who published the charts or instrument procedure plates that were being used at the time
of the incident? Please tick.
Jeppesen Airways Manual
Airservices Australia - Departure and Approach procedures
Other. Please specify......................................................................................................
8. Were there any problems with the procedures or charts which made it difficult to comply
with Air Traffic Control requirements?
Yes No
......................................................................................................................................................
..........................................................................................................................................
21
......................................................................................................................................................
......................................................................................................................................................
......................................................................................................................................................
..............................................................................................................................
9. Have you ever carried out this procedure before?
Yes No
If Yes, when did you last perform this procedure?
................................................................................................................................................
10. How often do you fly to this destination?

................................................................................................................................................
11. Did you refer to any ‘route briefing’ (audio visual or printed) material in preparation for this
flight?
Yes No
11a. If Yes, did the briefing material prepare you for the air traffic control instructions you
received during this flight?
Yes No
Please comment further.
......................................................................................................................................................
......................................................................................................................................................
......................................................................................................................................................
..............................................................................................................................
12. When was the briefing carried out for this particular procedure? (eg. approximately 10
minutes before top of descent, approximately 15 minutes before push back)
................................................................................................................................................
13. Was the original clearance/instruction modified in any way or cancelled?

Yes No
......................................................................................................................................................
......................................................................................................................................................
......................................................................................................................................................
......................................................................................................................................................
......................................................................................................................................................
..................................................................................................................
14. How often do you fly a SID, STAR or SRD? Please tick where applicable.
SID STAR SRD
Every flight
Most flights
Seldom
22
15. Did any aircraft equipment fail or disengage prior to this incident?
Yes No
......................................................................................................................................................
......................................................................................................................................................
......................................................................................................................................................
..............................................................................................................................
16. What changes could be made to prevent this incident happening in the future?
......................................................................................................................................................
......................................................................................................................................................
......................................................................................................................................................
......................................................................................................................................................
......................................................................................................................................................
..................................................................................................................
Please return this form to BASI via,

1. Fax on 06 2471290, or
2. Address a business sized envelope to
BASI,
Reply Paid 84
FTC INC,
Bureau of Air Safety Investigation,
PO Box 967,
CIVIC SQUARE ACT 2608. AUSTRALIA
NO POSTAGE IS REQUIRED IF POSTED WITHIN AUSTRALIA.
If you have any specific questions regarding this report please contact
Peter Wigens by telephone at
06 274 6460,
Fax 06 247 1290, or
Email [email protected]
23
APPENDIX 2 - SURVEY RESPONSES
Question 1
THIS INCIDENT HAPPENED WHILE FLYING....
HCRPT Non-HCRPT ALL INCIDENTS

SID 6 0 6
STAR 15 1 16
CLIMB 2 4 6
ARRIVAL - other 0 3 3
DEP - other 0 1 1
SRD 2 3 5
ENROUTE 2 1 3
Question 2
PLEASE DESCRIBE WHAT HAPPENED. TRY TO GIVE AS MUCH DETAIL

AS YOU CAN.
1 3/8/96 SYA_01059
The crew was distracted from level off @050 due to instructions from ATS and read back.
Moments prior to reaching our assigned alt (A050) on the Jet 3 SID we received instructions to
turn to 090 to join the 059R to Nobar. I was then asked by Flying Pilot, the F/O to tune in the
VOR to fulfil this request. At the time the ATS asked if we were at A050, I said “Alt” to my F/O
and told him to “descend now”. When ATS called and asked alt, we had reached approx 5780
- 5800 and no higher. We descended back toward A050, but ATS told us to maintain 5500’.
Just prior to being asked if we were at 050, we were given traffic and I acknowledged visual
contact at 1030 position and 1.5 to 2 miles. Using std SAT take off procedures our aircraft
performance was very good due to out lower weight (approx 275m3) and cool temp (approx
13C). When instructions were given, our climb was approx 2500’ - 3000’ per min. The F/O
was flying, and he was distracted by the ATS instructions as was the Flt Eng who was
monitoring both the radio instructions and aircraft instruments. Due to rate of climb and the
ATS instructions all happening within a matter of seconds, we exceeded our assigned alt by
approx 800’. We apologise for this incident.
2 6/6/96 PHA_00891
On being cleared to 4000’ I selected 3000’ on the assigned altitude selector. I had just
adjusted the altitude panel lights prior to landing. I may have been distracted when pax asked
me a question around the time of the instruction. I acknowledged the 1000’ to go signal at
4000’ and continued descent toward 3000’. I reached 3300’ when I was asked by approach to
confirm I was maintaining 4000’, I replied negative - understand cleared to 3000’. I
immediately climbed toward 4000’. At 3800’ I was asked by approach to verify altitude. I
replied 3800’ and was told to maintain 3800’. After the conflict had passed I was cleared for a
visual approach to RWY 11.
24
3 8/6/96 CSA_00273
Whilst taxying Cairns Ground asked if I would accept an A2 intersection departure, which I
declined. I was instructed to contact Tower who cleared me to ‘back track and expedite due
traffic on final’. I back tracked as quickly as possible, called ready and as I turned the aircraft
to line-up was given an instruction that I recall as “turn left heading 130 degrees, climb to 2000
feet clear for take-off”. I acknowledged, set the aircraft’s heading bug and assigned altitude
indicator and took off.
On contact with Cairns Departures I advised that I was turning left heading 130 degrees on
climb to 2000 feet. I am familiar with the terrain surrounding Cairns and was aware that
heading 130 degrees was taking me towards high terrain, however I was not concerned at the
time because the prevailing conditions enabled me to remain visual with the tops of the
highest terrain. I assumed ATC had given e that heading to clear the departure path for
runway 15. My airways clearance was for Hamilton Island via Innisfail, track 153 degrees. I
noted during my pre-take off brief that the radar 7 departure runway 15 indicates headings
between 030 and 350 degrees but assumed ATC could assign other headings depending on
the prevailing conditions. Passing abeam the Cairns City Centre I was considering requesting
a change of heading due to the terrain (although I estimated that my rate of climb would
enable me to clear the terrain) when Departures asked me to “confirm turning onto heading
030 degrees”. I acknowledged and commenced the turn. I was then asked if I was visual,
which I confirmed. During the turn I became concerned that the misunderstanding regarding
the heading may have been my fault (ie that I had incorrectly set the heading bug as I turned
the aircraft to line up) and was concentrating on what had been said between myself and ATC.
I was flying the aircraft by hand, visually and did not pay enough attention to the altimeter.
After completion of the turn I noticed that the altimeter was indicating 2600 feet (rate of climb
appro 1000 fpm), I momentarily levelled off and was about to commence descent back to
2000 feet when I was cleared to 7000 feet.
I do not have a clear recollection of my reed back of departure instructions to the Tower,
however I am certain that I advised the Departures Controller that I was turning onto heading
130 degrees as I was reading straight off the heading bug which was set on 130 degrees.
4 13/6/96 MLE_00351
The requirement issued by air traffic control was received after the descent was initiated.
When it was apparent that we were not going to meet the requirements a vector of 250 was
given and we commenced a rapid descent to 9000’ immediately. We were then vectored
back to intercept the runway 16 localiser for an ILS approach. Melbourne was experiencing
foggy conditions on this particular night.
5 14/6/96 CGT_00181
<< No reply >>
6 22/6/96 CSA_00278
I maintained 6500’ as instructed by app controller then he gave me instruction “Track DME14”.
I understood it as “descent 4500’ at 14DME in DME arr.” at the position about DME22~23 off
CS. While descending 5500’ I received ATC “maintain 5500’ from app controller then I did so.
(At that time, it was VMC condition around the aircraft. I saw the terrain clearly)
7 23/6/96 MLA_00543
Correct QNH not set at transition lvl. When maintaining 3000’ assigned alt - actual alt 2500’
(QNH = 995).
8 23/6/96 SYE_00029
After contact with SYD arrival we requested descent at 140NM from SYD VOR. We track
inbound 161 and during descent to 10000’ which ATC instructed us to maintain 11000’ so we
follow the ATC’s instruction and maintain that altitude.
25
9 25/6/96 MLT_00060
After departing RWY 35 Melb, I was cleared to overhead the ML VOR and to 3000’. Further
three heading alterations occurred in a short space of time as I approached 3000’. My scan
was temporarily distracted and I picked up the penetration just as ML TWR also picked it up at
3600’. On arrival at SWH I contacted the controller involved, and also notified the company.
10 25/6/96 ADA_00073
After extensive weather avoidance aircraft cleared to 9000 feet. Aircraft then cleared to 3000
feet. Before reaching 3000 feet cleared to 2000 feet for the ILS (we understood)
Jepp plate for ILS 23 states: aircraft from N/W may be radar vectored by ATC for ILS intercept
at 2000 feet. I assumed this was happening.
Workload high due weather avoidance, some wind shear/turb also warned by ATC possible
hold.
We were discussing holding as...

(1) in the hold we want to be 240 kts approx clean (for noise and fuel consideration)
(2) at the same point on final app I need to be 170 kts & landing configuration.
We were working out the best way to fly this in case of (a) holding or (b) being cleared straight
in.
Also with EFIS/FMS aircraft once having captured the ILS, much reselection/programming is
required to come out of ILS capture/enter hold/recapture ILS and close in holding for us is
unusual.
I think in general higher level holding further out is preferable where possible.
I apologise if we appeared to ignore ATC instructions but we both understood the clearance to
be “cleared to 2000 feet for the ILS” (not on the ILS).
Outside of Australia a step descent on the ILS is most unusual, it entails more R/T and means
the aircraft has to level at say 2000 feet (going above the G/S) is unable to get further
clearance due ATC R/T congestion.
Would it be possible to just clear the aircraft to 3000 feet and when on a suitable heading
“clear ILS 23” ? Avoiding the step descent.
Also if holding required is it possible to hold at a higher level further out ?
11 27/6/96 SYA_01070
The PF followed CHEZA 2 arr in managed des mode. According to a/c displays over WHALE
we were at 8200’ in alt capture mode (alt*) with decreasing vis.
12 1/7/96 SYA_01074
Confirmed: CHEZA II arrival
Altitude: Cannot confirm or deny; however A080 not substantiated. RWY changes and circuit
patterns in evidence and therefore alt requirements changed.
13 2/7/96 SYA_01075
We were tracking as per STAR in LNAV/VNAV - RIVET 3. Height and altitude controlled by
radar. We comply to radar alt clearance.
14 4/7/96 SYA_01078
Prior to TAMMI ATC passed “Expect radar vectors downwind”. The LN was routed TAMMI -
CF RW34L. We were watching traffic on approach 34R. At TAMMI a/c commenced a R7 to
CF RW34L. We asked ATC can we proceed base leg or continue into VOR. ATC said
“Continue in toward VOR”. Turn was immediately reversed. Conditions ____ and no
26
conflicting traffic seen. Shortly afterwards ATC gave vectors 150 D/W and handed off to next
controller. No comment was made at the time.
15 13/7/96 PHA_00916
In the FMS was preloaded STAR for arrival into Perth instead of FPL track to PH VOR. The
crew failed to check that this is not in compliance with FPL. There was not any instructions or
clearance from ATC to follow to PH VOR or to perform STAR.
16 17/7/96 SYA_01085
FMGS database on the aircraft had a routing after Richmond RCH-MDG-NYN (route H202) on
database cycle 20June-18July. However, Computer Flight Plan had routing on UH226 (RCH-
NYN). Aircraft was flown according to FMGS data routing. Hence ATC queried our route
after RCH.
17 21/7/96 SYA_01086
The reason was the flying pilots finger problem in programming the approach.
18 25/7/96 SYA_01092
RIVET 3 arr was given and instruction to descent to FL210 was initially issued but changed to
FL190 and FL160 subsequently when very close to RIVET. Autopilot did not level off a/c at
FL190 but went through (reasons unknown) manual cont. was initiated. After entering hold at
RIVET, a new heading was given by radar. Then follow by radar vector to TAMMI, a further
clearance “Direct to TAMMI, RIVET 3 arr” was issued when few miles from TAMMI. Pilots
were looking out for many other traffic around for safe separation. A/c went through TAMMI,
without turning right to Syd.
19 25/7/96 SYA_01093
We had taken off 16R on a RI5SID with 5000’ initially when reaching about 10DME SY, we
assigned another higher altitude. These altitude instructions ,made us think that altitude
restriction on SID chart came to no longer effect. So, I decided to turn right at 10 DME SY
without any altitude concern.
20 25/7/96 SYA_01089
Sydney clearance delivery issued us with a West Maitland 7 SID for departure. We were
cleared to taxy by SYD GMC to runway 16L (he offered us intersection ‘G’ but we requested
and were given intersection ‘F’). On being given take-off clearance by SYD TWR we were
instructed to____this we did on turning to intercept the radial as per WMD 7 SID. The
controller as I recall removed the speed control and cleared us to climb unrestricted. Shortly
after he asked us to confirm that we were on a WMD 7 SID that we confirmed, and after
passing east of the coastline he cleared us direct to Coolangatta. At no stage (apart from
asking us to confirm our SID) did any controller give any indication that our clearance was
incorrect.
21 24/7/96 BNA_00330
When turning off the downwind 119R to BNE VOR, I was under the impression that we were
cleared towards about 5 miles final for visual approach. I understand from the approach
controllers report that this was not the case.
22 31/7/96 SYA_01098
We were waiting for take-off and tower control told us to go back to clearance freq. and then
SYD clearance gave us a new clearance. We understood that we were cleared after airborne
to track 102 radial out of SY VOR on route.
23 1/8/96 SYA_01100
<< as per attached letter >>
Whilst enroute to Sydney we were given a RIVET 3 FL330 arrival. I programmed the aircraft
Flight Management System Vertical Profile to begin descent at Cullerin to be at Taral at
FL250, and TAMMI at 8000’ as required by the STAR. Between Taral and TAMMI we were
cleared to 7000’. This was later amended to maintain 10000’. Just prior to TAMMI we were
27
cleared to 6000’. We then immediately commenced a descent rate of 2500 per minute. I do
not recall the actual height that we passed over TAMMI.
24 9/8/96 SYA_01101
I was cleared to Sydney airport with the LETTI 3 arrival after passing YANGO as profiled. I
increased descending rate to meet altitude requirement at or below 8,000’. While descending
I had to use anti-icing, airspeed decreased to 250kts at 10M using speedbrake, which made
me less careful about altitude restriction and resulted in altitude deviation.
25 12/8/96 SYT_00162
I was given clearance “<< A/C >> cleared to taxi to RWY34L via G2 RWY25”. This clearance
was repeated to ATC. On taxiway G ATC asked us to use RWY25. But due to gross weight
limit, we requested to use RWY34L. Because I saw an aircraft departing on RWY25, we
verified taxi clearance with ATC. ATC replied “<< A/C >> clear to RWY34L via G2 hold short
RWY25”. At this moment we were just passed holding line G2. ATC than came over and said
“<< A/C >> stop”.
26 12/8/96 PHA_00928
I was cleared to FL280 which I thought I set on the altitude alert. However when I levelled out
it was at 290 which was on the altitude alert. ATC advised.
27 13/8/96 ENT_00138
After acknowledging inst from dep, I called EN TWR 125.1 at what I believed was FGN & EN
RWY35 visual. Part way through the turn onto final, I realised (saw lead in strobes) I was
lining up for ML RWY34. I also noted that my ADFs were not pointing to the RWY I had visual
but actually EN now visual to me. I realised my error and as I started my turn back on to base
for EN RWY35, EN TWR inst me to turn right. I complied, subsequently found the correct
location of FGN and completed landing at EN without further incident.
28 16/8/96 MLE_00389
<< A/C >> tracked over SBG and outbound SBG to AY 041 on SBG NDB. AY VOR was
turned and identified and the track intercepted. However the bug was set at 031 on both
VORs instead of 041. This resulted in the aircraft intercepting the 210 radial in lieu of the 220
radial.
29 16/8/96 ADE_00071
After departure, over point “AR” proceeding to “Woomera” instead of direct to “Ayers Rock”.
30 16/8/96 PFT_00178
Passing outer Harbour position visibility was restricted but still VFR. On siting runways ahead
and to my left, considered I was too close to both runways to cut across their takeoff paths.
31 16/8/96 PHA_00932
On line-up RWY24R, Jandakot Tower cleared me for take-off and make “visual departure”.
32 17/8/96 SYA_01109
I could hardly catch the assigned altitude in the ATC instruction, but I believed that it was
4000’ because there was no correction after PHF’s repetition to the ATC. When the aircraft
reached at about 6500’, the ATC advised that the assigned altitude was 7000’. Then I
realised for the first time that it was not 4000’ but 7000’.
33 19/8/96 PFT_00179
Intended joining downwind 21R due to lack of concentration I joined base for 03L.
34 19/8/96 SYA_01112
C. A. Safety Authority reports that << A/C >> crossed WHALE at 10800’.
28
35 19/8/96 SYA_01113
After take off in very bad weather above 800’ we turned left to intercept the 102 radial. Once
the turn was initiated the controller came on to question us about the turn; we replied that we
were turning to intercept the 102 radial. The controller asked us if we were turning to intercept
the 126 radial and we again replied that we were intercepting the 102 radial. Then the
controller came on and said to us to proceed and intercept 102 radial. The controller asked us
what clearance had we received and we read it back in full form.
36 20/8/96 SYA_01114
On departure BK I was cleared for a Radar 3 Pager departure. On line up I was instructed to
turn left onto a HDG 290 maintain 3000’. This I duly carried out. I was instructed to call SYD
Dept, which I did, advising HDG and on climb to 3000’. The controller again advised maintain
3000’ which I acknowledged.
The aircraft was light and climbing at approximately 800 - 1000’ per minute. I was distracted
by having to reset the mixtures and as I was resetting the aircraft passed through 3000’. I
realised the altitude had been exceeded as it approached 3300’ and pushed the aircraft down
again to regain the correct heading. As I did this the controller cleared me to climb to 5000’. I
then resumed the climb. It was then that the controller asked me if I had gone through the
altitude restriction which answered that I had. He then said I have you at 3500’ which I was at
the time. All this happened after I was cleared to 5000’.
37 25/8/96 BNE_00860
Flight was planned on FL350 cruise with a step climb at Ikuma to FL390, as indicated in the
computed flight plan. ATC had given clearance to climb to FL390, to be set before KIKEM. At
FL350, cruise speed was reduced from time to time for rough air penetration. At about 50NM
from KIKEM a climb was initiated. We had just crossed KIKEM at about FL385. The First
Officer reported the position including passing FL380 for FL390.
38 26/8/96 SYA_01118
Crew cleared RIVET 3 STAR to Sydney. Given heading to Sydney VOR LOC deselected as
not holding rad, as HDG used. FMS programmed Taral @FL 230 and 320kts, TAMMI
@7000’ and 250kts. Crew not aware that they passed TAMMI @9300’. All standard callouts
used, briefing done, sterile cockpit talked about on previous flight.
39 26/8/96 SYA_01119
I flew over the point which is located 20DME north of SYD at FL112. There is an altitude
restriction at or below 8000’ if fly on STAR LETTI THREE arrival.
40 28/8/96 SYA_01120
See description of incident << as per ESIR >>. Correction to text - a/c altitude at 20DME was
10,300’ not FL130.
“<< A/C 1 >> had been holding at TARAL due traffic. When it’s holding was cancelled
the a/c was vectored for sequencing and then instructed to intercept the 229SY VOR radial
and to resume the RIVET 3 arrival. Approaching 20NM SY the altitude readout was observed
to be about FL130. << A/C 2 >> was approximately 15NM SW Sydney on a rep so << A/C 1
>> was turned left to a heading of 360 to ensure separation was maintained. This was a very
busy period, with high workload for all involved. Runway for arrival was 16.”
29
Question 3
IN YOUR OPINION, WHY DID THIS INCIDENT HAPPEN?
1 3/8/96 SYA_01059
The Air Traffic Services instruction given to us as we approached assigned level distracted all
three crew members just long enough for us to accidentally exceed our altitude. The ensuing
request as to assigned altitude also momentarily distracted the crew members. The actual
altitude warning was believed to be the trim horn at the moment but was later proven to be the
altitude alert warning of an over shoot.
2 6/6/96 PHA_00891
Possibly due to lighting change at the time of selection of altitude or due to distraction from
pax. asking question around the same time.
3 8/6/96 CSA_00273
1. There was a misunderstanding regarding my assigned heading.
2. I inadvertently climbed through my assigned level.
4 13/6/96 MLE_00351
The minor problem with VHF COMM1 and discussions regarding our actions in the event of
an unsuccessful approach into Melbourne were distracting us from the primary task of flying
the aeroplane. However I accept responsibility for my error in judgement resulting in this
incident.
5 14/6/96 CGT_00181
<<preoccupied with serviceability of a/c and possible need to return to Coolangatta>>
6 22/6/96 CSA_00278
For the Air Traffic Control - It was a little difficult to understand what he wanted to mean by the
word “Track DME 14”.
For the pilot - I didn’t confirm the meaning of the word.
7 23/6/96 MLA_00543
1. Due to several distractions before and after transition level, crew failed to set altimeters.
2. No procedural checks in cockpit or Air Traffic Control exist to verify altitude until at low
altitude on or near final approach (where terrain/traffic conflict is most likely).
8 23/6/96 SYE_00029
I understood that altitude restriction of “YANGO” is cancelled by instruction to descend to
10000'.
9 25/6/96 MLT_00060
A very heavy workload just as I was approaching 3000’ together with insufficient prioritising in
the cockpit at the time of the incident.
10 25/6/96 ADA_00073
Aircraft proceeded as we thought the clearance was given. We did not realise that clearance
below 3000’ was “on the ILS”.
11 27/6/96 SYA_01070
The mix IRS position used for descend calculations in managed DES mode may vary from
real one after 3hrs flight, PF crosschecked it true DME readings which also have an
instrument proximity. The mode C delay also may be added.
30
12 1/7/96 SYA_01074
In attention to altitude constraints.
13 2/7/96 SYA_01075
The controller cleared us to maintain 10,000’ without further clearance until TAMMI. Then
mentioned to be given radar HDG after 20DME. We were fully aware and alert on that.
Altitude still controlled by radar. Then given descend to 6000’, HDG 340. This was after
passing TAMMI. This approximately take us to 5NM downwind of WPB of which is shown on
my ‘ND’ point is WPB245/5NM then to 4000’ then to 3000’ (HDG 060 then 130) then to
intercept LL2 R/W16. Asked to declare visual.
14 4/7/96 SYA_01078
It was not clear from radar <<Air Traffic Control>> instructions when the radar vectors would
begin. We felt we were getting high and very close. We had assumed we would come off
TAMMI into a base leg for R/W34L and that is why we asked for clarification from radar <<Air
Traffic Control>>.
15 13/7/96 PHA_00916
To preload a possible STAR in FMS company route is usual practice for data base supply.
When entered in the Perth area crew did not receive any specification of type of arrival. Also,
they was not warned that Perth Air Traffic Control working on presumed situation.
16 17/7/96 SYA_01085
Checking of the FMGS data routing was inadvertently skipped and we flew on the wrong data
routing to MGD.
17 21/7/96 SYA_01086
The F/O had programmed the app. WHALE/Centre fix R/W16L. The aircraft was flying in
LNAV mode and turned towards the centre fix. Both pilots realised that was happening at the
same time as the traffic controller.
18 25/7/96 SYA_01092
Compounded workload onto pilots as a result of:
1. 3 FL changes within short range from RIVET
2. Autopilot failed to level off at FL given, possibly due to high rate off descent. Pilot had to
take over manually.
3. Cancelled holding at RIVET followed by radar vector due to heavy traffic. Then revert to
RIVET 3 arr. + pilots were busy looking out for traffic around.
19 25/7/96 SYA_01093
After take off and before reaching 5000’ and 10DME we received an amendment to our
clearance to climb to a higher level. So this made me make a right turn before reaching 6000’
at 10DME.
20 25/7/96 SYA_01089
(A) A basic assumption my part that the SID that had been issued to us was the correct one
and indeed failing to question its validity with Air Traffic Control.
(B) Issuance of an inappropriate SID to us by Air Traffic Control and similarly failing to ensure
we were issued with the correct one.
21 24/7/96 BNA_00330
I was not aware that the incident had happened until I saw the report from CASA. As far as I
can recall, the ATIS reported that ILS 01 was OK, and we expected a VOR or visual approach
to RWY01. I had inserted X miles on legs page_____ but I am not sure if I activated the
segment from where we left the____.
22 31/7/96 SYA_01098
The crew of the flight interpreted the first clearance received was no longer in effect after the
second instructions was given.
31
23 1/8/96 SYA_01100
The assumption that the requirement to be at 8000’ at TAMMI was not now applicable - but
not clarified by Air Traffic Control or the crew.
24 9/8/96 SYA_01101
In my opinion it happened because I maintained high speed and did not control it properly
considering the altitude restriction as required and did not invite Air Traffic Control cooperation
in _____ for a possible deviation.
25 12/8/96 SYT_00162
Initial clearance there is no hold short instruction RWY25. When << A/C >> on G2, we got
clearance hold short of RWY25. At this moment I just <<stop>> over G2 holding line.
26 12/8/96 PHA_00928
Unable to explain, but more attention is being given to altitude clearances since the incident.
27 13/8/96 ENT_00138
FNG was not lit and is hard to find. At night there is similar black spot amongst the suburban
lights lined up with ML RWY34 which I obviously mistook for FNG which lines up with EN
RWY35.
28 16/8/96 MLE_00389
Pilot error - incorrect track set on VOR display (031 [ML -> SAG] in lieu of 041)
29 16/8/96 ADE_00071
I’ve misunderstanding about clearance “ADE-AR-AYERS ROCK”. Because there is no word
“DIRECT” on this clearance (From “AR” to “AYERS ROCK”) that mean I have to fly follow the
airways (AR-WOOMERA-AYERS ROCK).
30 16/8/96 PFT_00178
Unfamiliarity with that particular area, finding ourselves on the wrong side of airport and too
close to any outbound traffic that may been operating.
31 16/8/96 PHA_00932
Because I assumed that a visual departure - there was no further need to continue RADAR
WEST DEPARTURE.
32 17/8/96 SYA_01109
Because I assumed the assigned altitude in the Air Traffic Control instruction to be 4000’
without confirmation, in spite of that I could hardly catch it.
33 19/8/96 PFT_00179
Flew to Whyalla worked very hard for the time I was there (building trade). Flew home in
marginal but safe weather. At trips end I had a concentration lapse which I have never done
before and I assure will never happen again.
34 19/8/96 SYA_01112
At the moment I don’t remember but maybe it happened due to the weather conditions or
turbulence at the time. Sincerely, I don’t remember this fact.
35 19/8/96 SYA_01113
The crew was very concerned about the weather conditions for take off and departure. We
actually had a loss of airspeed during take off and turbulence was encountered once airborne.
These facts took away some of our attention from the SID. We turned to radial 102 since it
was in our clearance.
36 20/8/96 SYA_01114
Unfortunately this incident occurred by being distracted by carrying out engine management at
a time when more attention should have been paid to maintaining altitude limitation.
32
37 25/8/96 BNE_00860
During step climb, as we entered smoother flight conditions, managed speed was selected
which traded rate of climb for increase in speed. I had not factored in the time needed for the
aircraft to regain managed speed. This had an adverse effect on climb performance.
38 26/8/96 SYA_01118
Crew not sure why. Only can assume a breakdown in monitoring aircraft glide path progress.
Could be when PMS levels off at intermediate alt, throttles not closed completely resulting in
a/c being high.
39 26/8/96 SYA_01119
After flying track outbound of YANGO holding pattern, we were instructed by Air Traffic
Control as “DIRECT LETTI” with an assigned altitude. But the Air Traffic Control did not
mention about STAR (LETTI 3 ARRIVAL). So we recognised that radar vector would be
provided instead of STAR.
40 28/8/96 SYA_01120
<< Pilot received radar vectoring to 360, cancelling the STAR, then later received vector to
intercept 229 radial. The pilot did not receive instr. to resume RIVET3, and at no stage
confirmed this to Air Traffic Control. Pax distractions occurred throughout. >>
Question 4
WHICH OF THE FOLLOWING WERE ENGAGED/DISENGAGED AT THE

TIME OF THE INCIDENT?
HCRPT Engaged Disengaged No answer

Auto Pilot 21 5 1
Auto Throttle 21 4 2
Flight Director System 25 1 1
VNAV 15 10 2
LNAV 16 7 4
Non-HCRPT Engaged Disengaged No answer

Auto Pilot 6 7 0
Auto Throttle 4 4 5
Flight Director System 5 4 4
VNAV 1 4 8
LNAV 1 4 8
33
Question 5
DID YOU HAVE ANY DIFFICULTY UNDERSTANDING THE AIR TRAFFIC

CONTROLLER’S INSTRUCTION?
YES NO
HCRPT 4 23
Non-HCRPT 1 12
Total 5 35
3 8/6/96 CSA_00273 YES

Pilots are often asked to expedite departure by Air Traffic Control. I realise that we are not
obliged to co-operate, but generally we are keen to assist where ever possible. Although I am
sure the Tower controller was clear with his instructions the combination of trying to be
expeditious while performing line-up checks while receiving departure instructions may have
led to the misunderstanding regarding the assigned heading.
6 22/6/96 CSA_00278 YES

If App Controller want “maintain 6500’ until DME 14” by the “Track DME 14”, the former
expression is much easier for us to understand the instruction without doubt.
20 25/7/96 SYA_01089 YES

I was aware that a WMD7 SID was not apparently applicable to R/W 16R (confirmed by FMS
database and Aerad SID book) but incorrectly assumed that as no change of instruction had
been given by either Delivery, Ground or Tower Controllers the routing was the desired one.
29 16/8/96 ADA_00071 YES

I have difficulty about pronounce & slang.
40 8/8/96 SYA_01120 YES

<< Pilot did not receive Air Traffic Control instructions. Air Traffic Control assumed
instructions were received but at no stage received confirmation from pilot >>
1 3/6/96 SYA_01059 NO
However, the Air Traffic Services instruction came at an inopportune moment with regard to
rate of climb and position of the aircraft.
10 25/6/96 ADA_00073 NO
But we thought we were cleared at 2000’ for the ILS.
14 4/7/96 SYA_01078 NO
However we were unsure about how we were going to be tracked to get to the runway from
our position at the time. The term “downwind” was not clear from our position since we were
already downwind of the runway.
15 16/7/96 PHA_00916 NO
There was not instructions. Even when the crew has to comply with FPL we used to receive
“Follow FPL route” acknowledge.
34
21 24/7/96 BNE_00330 NO
I suppose the no answer is somewhat contradictory as the controller states that there was
language difficulties involved.
27 13/8/96 ENT_00138 NO
I did however believe dep inst. me to call EN TWR turning final at FNG.
32 17/8/96 SYA_01109 NO
But it was hard for me to catch the assigned altitude at the incident.
Question 6
WHAT CHARTS OR INSTRUMENT PROCEDURE PLATES WERE BEING

USED AT THE TIME OF THE INCIDENT?
All aircrews used the correct charts when the procedure was undertaken.
Question 7
WHO PUBLISHED THE CHARTS OR INSTRUMENTAL PLATES THAT

WERE BEING USED AT THE TIME OF THE INCIDENT?
Jeppesen Airservices Aust. Other

HCRPT 26 0 1*
Non-HCRPT 6 6 1
Total 32 6 2
* Aerad charts
Question 8
WERE THERE ANY PROBLEMS WITH THE PROCEDURES OR CHARTS

WHICH MADE IT DIFFICULT TO COMPLY WITH AIR TRAFFIC CONTROL
REQUIREMENTS?
YES NO
HCRPT 1 26
Non-HCRPT 1 12
Total 2 38
8 23/6/96 SYE_00029
There is a possibility of misunderstanding that altitude restriction of YANGO by descent
instruction of lower altitude pilot might consider the restriction is cancelled.
35
23 1/8/96 SYA_01100
The changes in descent levels without clarification after the amended maintain 10,000’ and
the later clearance to 6,000’ that we were still required to be at 8,000’ over TAMMI.
Question 9
HAVE YOU CARRIED OUT THIS PROCEDURE BEFORE?
YES NO NO ANSWER
HCRPT 17 9 1
Non-HCRPT 10 2 1
Total 27 11 2
Question 10
HOW OFTEN DO YOU FLY TO THIS DESTINATION?
VISITS PER YEAR TOTAL

1 1
2 4
3 7
6 2
8 2
9 4
12 5
24 2
60 2
72 1
90 1
100 3
120 1
NO ANSWER 5
Grand Total 40
36
Question 11 & 11a
11. DID YOU REFER TO ANY ‘ROUTE BRIEFING’ (AUDIO VISUAL OR

PRINTED) MATERIAL IN PREPARATION FOR THIS FLIGHT?
11a. IF YES, DID THE BRIEFING MATERIAL PREPARE YOU FOR THE AIR
TRAFFIC CONTROL INSTRUCTIONS YOU RECEIVED DURING THIS
FLIGHT?
11 YES YES NO
11a YES NO N/A
HCRPT 13 7 7
Non-HCRPT 6 4 3
Total 19 11 10
PLEASE EXPLAIN FURTHER.
3 8/6/96 CSA_00273
I referred to the documents and charts normally used when operating around Cairns plus I
rang the departures controller to gain approval to track Cairns direct to Innisfail (indicated as a
“one way route on the charts). This was for the benefits of the pax as it is a very scenic route.
4 13/6/96 MLE_00351
The instruction was additional to the STAR procedure.
21 24/7/96 BNA_00330
The relevant charts for Brisbane Airport issued by Jeppesen was studied previously and
during the approach briefing.
24 9/8/96 SYA_01101
The briefing of company NOTAM and Jeppesen manual Australia page 10-2E (19 Jan 96)
were available in any approach situation.
27 13/8/96 ENT_00138
The chart (Melb VTC) is easy enough to read. The moving map outside the window of an a/c
on approach in the dark with a tailwind is not always representative of this.
28 16/8/96 MLE_00389
Air Traffic instructions were clear.
29 16/8/96 ADE_00071
That’s misinterpretation about the clearance between ATC & the pilot.
30 16/8/96 PFT_00178
As outlined previously, conditions were somewhat gloomy or obscured not being familiar with
area. I found the position warranted tuning away to keep out of the way. I should have asked
for a clearance to back track and re-enter app to 26R.
32 17/8/96 SYA_01109
Briefing materials are Jeppesen manuals, charts, NOTAM and so on.
37
33 19/8/96 PFT_00179
Received ATIS ERSA.
34 19/8/96 SYA_01112
I have no doubt about the STAR procedures.
37 25/8/96 BNE_00860
I have flown this route several times before and have been cleared to climb to FL390 at pilots
discretion with the requirement to cross the FIR boundary at FL390.
38 26/8/96 SYA_01118
Briefing mentions that “Sydney ATC is very strict about the height requirement on the STAR”.
40 28/8/96 SYA_01120
Normal review of STAR and expected approach with appropriate briefing to first officer.
Question 12
WHEN WAS THE BRIEFING CARRIED OUT FOR THIS PARTICULAR

PROCEDURE?
In all incidents the briefing was carried out with appropriate concern for
timing. The range of timing spanned from 5 minutes before the procedure, to
2 hours prior to the procedure. In general, the briefing was carried out in the
20 minutes preceding the incident.
Question 13
WAS THE ORIGINAL CLEARANCE/INSTRUCTION MODIFIED IN ANY

WAY OR CANCELLED?
YES NO NO ANSWER
HCRPT 12 14 1
Non-HCRPT 5 7 1
Total 17 21 2
IF YES, PLEASE EXPLAIN FURTHER
4 13/6/96 MLE_00351
The height requirement at BUNKY and the speed restriction below 10000’ were cancelled
prior to descent.
7 23/6/96 MLA_00543
1. High speed descent assigned for flow/separation
2. High speed descent below 10000’ assigned by approach control
3. Track change BUNKY to TIMZN requested and cleared.
38
8 23/6/96 SYE_00029
During LETTI 3 arrival, ATC vectored us to avoid CB cloud.
9 25/6/96 MLT_00060
Initial instruction was to track over the ML VOR visually. This was altered close to overhead
ML by three separate heading alterations.
10 25/6/96 ADA_00073
W/X avoidance then cleared to 9000’ then cleared to 3000’, then cleared to intercept LOC,
then cleared for the ILS.
12 1/7/96 SYA_01074
RWY changes & circuit patterns in evidence & therefore alt requirements changed.
13 2/7/96 SYA_01075
STAR - as per Jeppesen LNAV on ‘ND’ but the altitude was controlled by ATC.
14 4/7/96 SYA_01078
Originally told by ATC to expect STAR for RWY 16R. This was changed to RIVET STAR for
RWY 34L.
15 13/7/96 PHA_00916
There was a radar vectoring.
18 25/7/96 SYA_01092
The original clearance “RIVET 3 arr, descent to FL210 and reach FL210 by RIVET” was
changed to FL190 then FL160 hold at RIVET. After the hold, the holding was cancelled
followed by radar vector when near the TAMMI change to “direct to TAMMI & RIVET 3 arrival”.
22 31/7/96 SYA_01098
Just before takeoff they gave us new instructions.
27 13/8/96 ENT_00138
I think the radar heading was amended 10degrees (to the right) somewhere during the app.
30 16/8/96 PFT_00178
Only to clear 26L for landing.
31 16/8/96 PHA_00932
Was given radar west one departure then on line up Jandakot tower have me instructions for
a “visual departure”.
38 26/8/96 SYA_01118
Modified for separation. Crew given heading off STAR then put back on STAR.
40 28/8/96 SYA_01120
Original clearance was “RIVET 3 arrival” holding at TARAL with an altitude restriction was
given this clearance was cancelled and holding changed to Cullerin with (I think) another
altitude restriction. As we were about to enter hold at Cullerin clearance was changed again
to hold at TARAL.
39
Question 14
HOW OFTEN DO YOU FLY A SID, STAR, OR SRD?
HCRPT SID STAR SRD

Every flight 12 10 0
Most flights 13 12 9
Seldom 0 2 7
No answer 2 3 11
Non-HCRPT SID STAR SRD

Every flight 0 0 0
Most flights 3 4 7
Seldom 7 4 3
No answer 3 5 3
Question 15
DID ANY AIRCRAFT EQUIPMENT FAIL OR DISENGAGE PRIOR TO THIS

INCIDENT?
YES NO NO ANSWER
HCRPT 2 23 2
Non-HCRPT 2 11 0
Total 4 34 2
Question 16

1 3/8/96 SYA_01059
In this case observing the altitude warning and paying more attention to alt control rather than
Air Traffic Services instructions would have prevented the flying pilot from exceeding the
assigned level of A050. All crew members were trying to be certain we were conforming to
instructions and failed to observe the level off alt.
2 6/6/96 PHA_00891
1. Adjust lighting earlier.
2. Disregard pax questions at critical stage of flight.
3. Double check correct altitude set on altitude selector.
40
3 8/6/96 CSA_00273
None......It boils down to human error largely.
4 13/6/96 MLE_00351
I see no necessity for making any changes in this instance.
5 14/6/96 CGT_00181
Ring tower and get a local briefing prior to departure.
6 22/6/96 CSA_00278
If App Controller want “maintain 6500’ until 14DME” by the word of “Track DME 14”, the
former expression is much easier for us to understand the instruction without doubt.
7 23/6/96 MLA_00543
1. Reinstitute procedural cross check of QNH/indicated altitude at 5000’ or other altitude
between OCTA and transition LVL.
2. On initial call to appch control aircraft should advise of both assigned altitude and current
altitude....(Controllers are a safety resource too.)
8 23/6/96 SYE_00029
While following STAR Air Traffic Control should more be specific about altitude restriction.
(Mention about altitude restriction when deliver a descent instruction to the aircraft.)
9 25/6/96 MLT_00060
Normally on this type of departure there are few HDG alterations by Air Traffic Control so I
could only suggest to simplify the departure if possible. And to improve my departure briefing
and better manage workload in this environment.
10 25/6/96 ADA_00073
Normally clearance is expected to intercept the ILS on a HT & HDG. The step down
procedure on the ILS is most unusual outside of Australia. It entails more R/T and possible
misunderstanding. A “Clrd for ILS from 3000’ “ would prevent a repeat.
11 27/6/96 SYA_01070
I change the procedure for descending during SYD approaches. The crews will perform IDLE-
OP DES procedure ensuring that the aircraft will be at or below prescribed altitude before
reaching the point and without reference to a computed des path.
12 1/7/96 SYA_01074
Greater attention by crew.
Greater attention by Air Traffic Control on compliance.
13 2/7/96 SYA_01075
Give us height and/or altitude that is reasonable as to not infringe the STAR restricted height.
As crew, we do not question Air Traffic Control on height and/or altitude clearance, as we
expect their a/c separation procedures within their sector of controlled. We will comply, even
though sometimes infringe STAR alt restriction otherwise we shall comply to STAR in full
(track & alt).
14 4/7/96 SYA_01078
It would be helpful if it was made clear at what point the STAR would be cancelled on favour
of radar vectors, ie “Expect radar vectors after TAMMI”. We felt we were getting “Close and
High” for R/W34L and that is why we asked for clarification. I do not challenge the Air Traffic
Control controller’s instructions.
41
15 13/7/96 PHA_00916
1. The crew always has to ask specification of the route, if it is not clearly identified.
2. The PERTH Air Traffic Control has to inform the operators that they will work on presumed
manner.
16 17/7/96 SYA_01085
Crew to check both Computer Flight Plan and flight plan on the FMGS to ensure that the
aircraft is flown according to the Computer Flight Plan.
17 21/7/96 SYA_01086
Ensure that inserted inbound routes are complying with instructions when using LNAV and
autoflight system.
18 25/7/96 SYA_01092
1. If frequent change of FL is required, preferred earlier clearance given or a/c can also
descent in the hold if required to reduce workload.
2. Once radar vector is initiated very close to the a/port while traffic is heavy, prefer remain so
until on final rather than revert to STAR again while pilots are busy lookout for traffic around.
3. Pilots need to be trained on good crew coordination.
19 25/7/96 SYA_01093
I expect more coordination and advise from Air Traffic Control
20 25/7/96 SYA_01089
A) As an aircraft commander to ask for qualification of any Air Traffic Control clearance that
has ambiguity or potential for error or misunderstanding.
B) If prevailing conditions change a clearance status then it is also incumbent on any Air
Traffic Control unit to make sure an aircraft has a correct and appropriate Air Traffic Control
airways clearance.
21 24/7/96 BNA_00330
1. Ensure that issued clearances are received and understood.
2. To receive clearance for the actual approach to be performed at an earlier stage, so that
“assumed” procedures are not briefed and then wrongly executed.
22 31/7/96 SYA_01098
As a result of the previous misunderstanding pilots were gathered and informed and a revision
of all procedures for the airports we are operating into was done. Also a memo was sent to
them as a reminder.
23 1/8/96 SYA_01100
By Air Traffic Control: after descent levels given then cancelled for higher levels - confirmation
that the STAR has not been varied or cancelled.
By Executive Airlines: see attached operations manual amendment 4/96 dated 7/8/96:
“The purpose of this amendment is to eliminate any doubt or confusion, and to ensure that the
requirements of both the STAR and any limitations or variations, given by Air Traffic Control
are clarified, able to be met, and complied with.”
24 9/8/96 SYA_01101
I am terribly sorry not to observe the altitude restriction causing you trouble unnecessarily. No
comment on procedure.
25 12/8/96 SYT_00162
N/A
26 12/8/96 PHA_00928
N/A
42
27 13/8/96 ENT_00138
Clearer identification of visual reporting points or complete ignorance of them in marginal
situations relying on a pilot to spot them under IFR and in CTA in radar environment.
(marginal = high traffic periods / night / poor vis etc).
28 16/8/96 MLE_00389
Nil for Air Traffic Control
More diligence on behalf of pilot.
29 16/8/96 ADE_00071
Further details of any deviation, or notice to pilots from the briefing officer.
To give instructions in clear and simple words.
30 16/8/96 PFT_00178
The fault of being in the wrong place has to be my fault only. I dare say hundreds of VFR
aircraft use the same ___ and procedures without incident. They would not all be local pilots
either.
31 16/8/96 PHA_00932
Every pilot that I have spoken to, and one instructor also thought that a visual departure
cancelled radar departure - now I understand that while completing instrument departure to
look out the window for other aircraft.
32 17/8/96 SYA_01109
If I failed to catch the Air Traffic Control instruction clearly and were in the same situation in
the future, I would confirm it without hesitation.
33 19/8/96 PFT_00179
In my 310 hours of flying I have never been involved in any incident. I consider my flying by
the book my one and only misdemeanour will be sufficient to ensure I will never suffer a lack
of concentration again.
34 19/8/96 SYA_01112
I think that the Air Traffic Control could warn the pilot to correct quickly the situation. I don’t
deny the fact. My apologies for the happening.
35 19/8/96 SYA_01113
Regardless of weather conditions we need to emphasise more the details of a SID before
take-off.
36 20/8/96 SYA_01114
One thing that is lacking in most light aircraft is that the assigned altitude indicators do not
have altitude alert. I think if these where fitted then if altitudes where exceeded it would be
only by 200’ as there are times in the single pilot IFR environment that the pilot can be busy
with a low altitude restriction.
37 25/8/96 BNE_00860
To initiate the climb earlier. If the cruise speed had been reduced for rough air penetration, to
factor in the time adjustment for the aircraft to regain managed speed, which can affect climb
performance.
38 26/8/96 SYA_01118
- If Air Traffic Control observe any possible deviation (or similar incidents) to query the crew.
This way we monitor each other in the cockpit & Air Traffic Control/crew monitoring takes
place.
- PMS path v PMS descent manual will get to height but sacrifice speed.
- Crew monitoring.
- Callouts.
- Sterile cockpit.
43
39 26/8/96 SYA_01119
If the Air Traffic Control assigns the route like “Direct LETTI”, they should mention about the
STAR every time, otherwise the pilots may recognise that the radar vector is provided. Maybe
the words “Comply altitude restriction” can help.
40 28/8/96 SYA_01120
Controllers must ensure that there is a readback of clearances of this importance.
44
APPENDIX 3
FURTHER TREND MONITORING
Since the completion of the 3-month study, BASI has continued to monitor
ESIRs. During September and October, FTC incidents continued to occur in
line with the trends confirmed in the study period.
Figure 6 shows that HCRPT aircraft were involved in 30% of reported FTC
incidents. Foreign operators accounted for 85% of all HCRPT incidents.
Private aircraft were involved in 26% of incidents. There was an increase in
the level of FTC incidents for commercial chartered aircraft, compared to the
study period.
FIGURE 6
Reported FTC incidents by statistical grouping, September–October
1996
0
Other Aerial Work
Military 7
Helicopter 0
Private 22
Business 0
Flying Training 11
Commercial Charter 14
LCRPT - Freight 0
LCRPT - Australian 5
HCRPT - Foreign Freight 1
HCRPT - Foreign 22
HCRPT - Australian 4
0 5 10 15 20 25
Number of Incidents
Figure 7 illustrates the distribution of FTC incidents by location. Again,

Sydney accounted for the greatest proportion of incidents with 37%, an
increase of 8% on the 3-month study period. The next highest level of FTC
incidents occurred at Melbourne, Brisbane and Bankstown with 9% each.
HCRPT incidents accounted for 53% of FTC incidents at Sydney, a decrease
of 29% from the 3-month study period. In real terms however, the number of
high-capacity FTC incidents in Sydney remained consistent with 8.5 per
month, compared with 9.3 per month in the 3-month study period.
45
Number of Incidents
0
5
10
15
20
25
30
35
1996
Melbourne
FIGURE 7
Sydney
Canberra
Cairns
Perth
Brisbane
Townsville
Darwin
Adelaide
Coolangatta
Rockhampton
46
Jandakot
Bankstown
Parafield
All other
Albury
Williamtown
Coffs Harbour
HC RPT
Archerfield
Essendon
Moorabbin
Maroochydore
Camden
Reported Failure to Comply incidents by airport, September–October

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CONTENTS

ABBREVIATIONS AND DEFINITIONS.......................................... v

EXECUTIVE SUMMARY .............................................................. vi

4. FINDINGS AND DISCUSSION.................................................. 6

5. ANALYSIS OF SURVEY RESPONSES .................................... 9

APPENDIX 2 - SURVEY RESPONSES ...................................... 24

ATC Air Traffic Control

ATS Air Traffic Services

BASI Bureau of Air Safety Investigation

CASA Civil Aviation Safety Authority

ESIR Electronic Safety Incident Report

FTC Failure to Comply

HCRPT High-Capacity Regular Public Transport aircraft

ICAO International Civil Aviation Organisation

LCRPT Low Capacity Regular Pubic Transport aircraft

LNAV Lateral Navigation

MTOW Maximum Take-Off Weight

SID Standard Instrument Departure

SRD Standard Radar Departure

STAR Standard Arrival Route

VOR VHF Omni Range

A Failure to Comply incident is defined as an air safety incident in which flight

During 1994 BASI recorded an increase in the frequency of incidents

This report draws on data collected during the comprehensive study of

The underlying factors in FTC incidents are:

• communication (of particular concern with foreign flight crews);

• SID and STAR design; and

• aircraft operating procedures.

1.1 Bureau of Air Safety Investigation trend monitoring

The Bureau of Air Safety Investigation maintains a computer database of

1.2 Definition of Failure to Comply

A Failure to Comply (FTC) incident is defined as an air safety incident in

1.3 Type of operation

Other Aerial Work

0 20 40 60 80 100 120 140 160

1.5 Failure to Comply incident trend at Sydney

Figure 2 presents the number of FTC incidents at Sydney, involving aircraft

June 1994 The former Civil Aviation Authority introduced STARs to

Nov. 1994 Opening of parallel runway (16L/34R) at Sydney airport.

Feb. 1995 New SIDs introduced at Sydney airport.

This report includes information relating to operations involving fare paying

The objectives of this study were to:

(a) identify trends of FTC incidents in Australia;

(b) analyse FTC incidents to identify common factors;

(c) identify potential solutions to the FTC problem; and

(d) make recommendations as appropriate.

The following information relates to the information received through the

4.1 Type of operation

Figure 3 indicates that HCRPT aircraft were involved in 42 FTC incidents in

Other Aerial Work 1

HCRPT - Foreign Freight 1

All Other HC RPT

4.3 Frequency of Failure to Comply Incidents

Table 2 shows the frequency of FTC incidents in relation to total aircraft

4.4 STAR and SID design within Australia

The development of STAR and SID procedures was reviewed.

• Some current ATC procedures relating to STARs do not follow accepted

• Compared with accepted worldwide practice, many Australian STAR