The ‘Ambidji
Report’ – a 180 page review, plus a 140 page appendix to the review – was
released on 15 July
2009.
Among the
findings of the review:
Moorabbin
Airport experienced 335,000 aircraft
movements during 2007/08, and recorded two Mid-Air Collisions (MACs) between
1999-2008 (see Table 3.2, p. 21).
Figures
sourced from Airservices
Australia, who
operate the Moorabbin Air Traffic Control (ATC) tower, indicate that Moorabbin
had about 310,000 aircraft movements during GAAP hours in FY 2006/07,
which increased to 350,000 movements during FY 2007/08 (Figure 4.1, p. 25)
The review
highlighted a number of serious accidents and incidents involving planes using
the busy aerodromes at Moorabbin and
Bankstown over the last 10
years.
A study of
Electronically Submitted Incident Reports (ESIRs) submitted from GAAP aerodromes
from January 2001-March 2009, shows that Moorabbin had two Mid-Air Collisions
(MACs), and an estimated 25 Accidents, 240 Runway Incursions, and 80 Failures to
Comply with instructions issued by ATC (Figure 4.3, p. 29).
Two MACs have
occurred in or within the vicinity of Moorabbin aerodrome in the last 10 years,
both involving aircraft in flying training circuits. Fatal accidents occurred on 29 July 2002 and 27 August 2008 (Table 10.3, pp 110-111). Actual collision rates for Moorabbin have
increased in the last 10 years compared to the previous 10 year
period.
Out of the
six surveyed GAAP aerodromes, Moorabbin recorded the worst figures for Runway
Incursions between 2000-2009 (60 incursions in 2007, and 60 in 2008). This is far ahead of
Bankstown (40 in 2007, and 38 in
2008) (Figure 4.6, p. 43). Airservices
and CASA rate runway incursions among the most serious threats to operational
safety.
A clear
rising trend in the number of Failure to Comply incidents is evident when all
locations are combined, and is clearly evident at Moorabbin,
Bankstown and Parafield (Figure
10.13, p. 134).
Ambidji
recognises that Airservices ATC personnel submit the majority of safety
occurrence reports within the GAAP environment, while Aircrew submit relatively
few safety incident reports. The Ambidji
Report found that safety incidents are being under-reported, and this failure to
report incidents is an untenable situation in 2009 (p. 32).
Ambidji
concludes that the current risks at GAAP aerodromes are unacceptable:
“Risks
associated with light aircraft collisions are currently intolerable at
Moorabbbin, Bankstown and Jandakot”
(Figure 11.7, p. 147).
“The societal
risk analysis shows that risk reduction measures are required (irrespective of
costs) at Moorabbin, Jandakot,
Bankstown and Parafield
due to the
tolerability limits being reached / exceeded” (p. 148).
“Baseline
societal risks are shown to be intolerable at Moorabbin,
Bankstown and
Jandakot
aerodromes ….. Immediate risk reduction measures to reduce risk to tolerable
levels are required” (p. 160).
“Current
(baseline) societal risks associated with GAAP operations at
Bankstown, Jandakot and Moorabbin
are intolerable when compared with the CASA risk criteria” (p. 167).
In summary,
the Ambidji Report identifies major deficiencies in current airspace and
aerodrome procedures, an unacceptable level of safety risk (particularly
concerning mid-air collisions), and an urgent need to reduce these risks.
Recommendations
