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Level Busts -
Threat or Opportunity? (Oct 2004)
by Capt. Jim Snee (ATC Liasion Manager & FKR
Fleet Manager) bmi
What is a level bust?
A level bust is
defined as ‘Any deviation from an assigned level in excess of
300ft (or 200ft in RVSM airspace)’ (HEIDI).
Why is a level bust a threat?
The immediate answer is obvious. The more
important issue is that despite a growing awareness of the problem –
and the publicity that has accompanied this awareness – the absolute
number of level busts has not declined significantly over the last 10
years.
Why do I claim in the title of this paper that
level busts present us with an opportunity?
Because we can do something about improving our
track record. That is ‘we’ as individuals, as co-pilots, as captains,
as trainers, as managers, as a company and as an industry.
And we can do this without much effort and
without much cost.
Why now?
10 years ago the phenomenon of level busts was
not a hot topic in Europe. UK NATS and UK CAA were
the first significant European agencies to recognise the issue and to
mount an initiative to counter the problem. You probably remember the
posters and those early exhortations that resulted in changes to our
SOPS – focused flight deck, r/t discipline and phraseology, proper
confirmation of cleared levels by both pilots, etc. Back then level
busts were seen as a peculiarly British issue. They only happened in
UK airspace – nowhere else in Europe! Who was kidding whom?
Happily that perspective has changed in the
intervening years. The issue is now recognised, not only on a pan
European, but on a global basis, as NASA, the FAA, Flight Safety
Foundation, NATS and Eurocontrol exchange information, statistics,
philosophy and effort, to combat the threat of level busts. 35% of all
ASRs filed within the
ECAC States
are level bust related. That’s a frightening number – over one third
of all reported incidents. Given that very nearly all of these events
are avoidable on the one hand, but could be catastrophic on the other,
I hope you begin to understand the need for positive action – and the
threat that you pose to yourself, and those around you, if you don’t
aspire to ‘best practice’.
And that is why there is an opportunity.
Best practice will resolve very nearly all level
bust scenarios. Eurocontrol, in association with IATA,
have just launched a major new initiative directed at the level bust
issue – The European Action Plan for the Prevention of Level Busts
(they’ll probably end up calling it EAPPL but so far they’ve resisted
the temptation!). Within the documentation of this initiative they
look at Aircraft Operator issues and they focus on 5 action points:-
1. Review SOPS to reduce the
likelihood of level busts.
Have we done this? - Yes.
Have we changed SOPS? -Yes.
Do we review SOPS? - Yes.
Do you routinely stick to SOPS? - Yes!?
2. Reduce flight deck workload by avoiding all
activity not directly related to the safe conduct of the flight.
Have we implemented this philosophy? - Yes
- focused flight deck, Restriction of PAs, Descent check/briefing
timings, etc.
Have you taken this on board? - Yes!?
3. Ensure clear procedures for altimeter
cross-checking and approaching level calls.
Do we have these in place? Yes.
Do you follow them? - You bet!?
4. Always confirm the clearance if any doubt
exists on the flight deck.
Is this enshrined in our SOPS? - Of
course!
And of course, you follow the rules?
5. Always report the level cleared to when
checking in on a new frequency whilst in the climb or descent.
Do we require this discipline? - Yes,
along with all r/t disciplines.
Do you comply?
I list these five action points because they cut
straight to the core of the problem. None of it is rocket science and
much of it is little more than common sense. If you were to start with
a blank sheet of paper and but 5 minutes to spare to produce a game
plan to reduce level busts I doubt that you would come up with a set
of guidelines that differed in any great detail.
(If you do, please send them in and we’ll
forward them to Eurocontrol! Ed.).
If the solution is that simple:-
1. Why is it that the industry is still
generating a constant percentage of violations
when measured against total movements?
2. And why is it that we as a company don’t
return an exemplary record in the level bust stakes when we operate to
these ‘best practice’ standards?
As ever, the answer to these two questions is
not to be found in one simple sentence. We can certainly influence the
internal issues but there are also significant external factors over
which we have no immediate control.
External Issues
We have no control over airspace procedures and
design, we have no control over ATC or controllers standards, we have
no control over the technologies employed within the system, we have
no control over chart design. Call sign confusion reigns supreme,
language difficulties abound and r/t clutter only increases with
traffic growth and ever more ATC sectors. SIDs and STARS become ever
more complicated in striving to embrace both increasing traffic
densities and environmental pressures. These all contribute to the
level bust pool.
We can advise and object and consult and be
consulted – and we do and we are - but we don’t control these
influences. The converse is true, they conspire against us which is
why our first, and best, line of defence are the internal issues.
You should be pleased to know that these
external factors are all also recognised by both IATA and Eurocontrol
and form an integral part of this initiative. Mechanisms are in place,
and continue to be put into place, to mitigate against a worsening
trend and to create a climate where level bust reduction prevails.
There is a strengthening partnership between the airlines, the ANSPs,
the regulators and the equipment manufacturers, to reduce the adverse
influence of these external factors.
We as a company play our part in this effort.
For example, we are involved in the callsign confusion debate, in
language issues, in procedure design, in controller familiarisation
campaigns, in IATA forums, in NATS task groups etc, etc. In short we
contribute energetically to the external debate. (And not just on
level busts, but that’s another story!).
The industry has developed
ACAS, the
regulators have mandated it and we use it. Similarly
STCA (the controllers equivalent of ACAS.) is now in place in most
EU States. These tools provide a safety net but that’s the long stop,
we need to work to achieve an environment where they’re never brought
into play. And that brings me neatly back to the internal issues
raised by my second question.
Internal Issues
The more observant of you will have noticed a
question mark at the end of each of my ‘responses’ to the 5
Eurocontrol/IATA recommendations. My query is deliberate because we
pretty much have these preventative measures already covered and yet
we still manage to feature in level bust stats, (albeit we have far
from the worst record, indeed we fare reasonably well). Even so, this
year we have so far recorded 7 events which means that not all of us
are following SOPS with the tireless and professional zeal necessary
to eliminate the problem.
Of course, no-one sets out on a days work with
the intention of becoming involved in a level bust, or indeed any
other incident. When it happens it’s always a case of a ‘gottcha!’ and
then a review - with hindsight almost always being a wonderful tool.
It’s easy to fall into the trap and difficult to shake off the remorse
and the hurt pride. The best policy is obviously to prevent the
occurrence in the first place. Staying firmly within the designed
framework of SOPS will greatly help to resolve most incidents before
they become a statistic or an incident.
UK CAA studies have shown that over 70% of level
busts fall into 6 general categories:-
1. Operation on SIDS.
2. Autopilot problems.
3. Failure to follow ATC instructions.
4. Altimeter mis-setting
5. Pilot handling.
6. Confusion over cleared level.
Our level bust history follows a similar trend. We’ve also had a
lightning strike induced incident (a bit of a ‘one off’, that one) and
I would now add another issue which is the ‘late re-clearance’
instruction - when existing high rates of climb/descent are involved –
more a controller issue really but we’re still the victim. Also
reflected in our history is the FAA observation that some 40% of level
busts occur because of confusion between FL110 and FL100 – a more
specific example of the CAA item 6.
The Opportunity
If you look at these major causal factors and
then set them against the script of our SOPS I think you’ll find that
we’ve already gone a long way to providing operational procedures
designed to greatly reduce, if not eliminate, these issues (insofar as
is possible). Not just with the baselines that the SOPS themselves
provide, but also within the training process too (remember the
highlights of the level bust training and videos that we featured this
summer?).
We need to remain active in improving techniques
further and to providing robust and relevant refresher training. But
we also need to create a culture that actively encourages our pilots
to use the defensive armour that we provide to best advantage and to
fully understand both why the SOP exists and why it’s in the best
interests of all to use it.
And that is probably the most important message
in this article.
To take just one of these items – ‘autopilot
problems’ – our SOPS require us to call ‘one to go’ and also to
monitor the FMA and to call/cross check ‘Alt Star’ (or ‘Delta’,
depending on fleet). If you only follow the rule on check flights no
one will catch you out - as long as you’re smart enough to remember
not to revert to type when a training captain is looking over your
shoulder. But the autopilot will get you every time, when, very
occasionally, it doesn’t work as advertised. As they say - it’s your
call! You can apply the same analysis to the other 5 causal factors
listed here.
There has to be a lesson in that simple, single,
example.
It has surely got to be easier to comply all the
time rather than only to order? And that’s why there is an opportunity
in all this. The SOPS are there to help prevent you getting caught
out, not to cause you to be caught out – think about it, neither
difficult, nor expensive either!
The definition of a level bust is very clear –
it requires a deviation from an ‘assigned level’. By definition then,
the violation occurs from within the aircraft, it is a deviation from
the level that the controller has instructed us to maintain. There may
be many and various mitigating and extraneous circumstances but it is
the crew who deviate and it is the SOPS which try to prevent you from
failing!
Conclusion.
I attended a workshop earlier this month hosted
by Eurocontrol and IATA on the subject of level busts. Many of the
speakers at this meeting were clear in their view that there is no
‘quick fix’ to the level bust problem. The issues, the causes and the
remedies are many and complex. This was a common theme throughout the
day and I lost count of how many times we were told that there was no
‘silver bullet’ solution.
I can see their point and it has considerable
merit but actually I don’t fully subscribe to this prognosis.
I have a more simple and a more optimistic
view:-
Good SOPS, well designed, justified and
understood, good flightdeck discipline, robust training and a clear
understanding within the pilot community of the necessity to implement
these SOPS – and all that they imply – will get us pretty close to the
elusive ‘silver bullet’ for which everyone seems to be searching.
Like you, I am but a pilot, is it really that
difficult?
Finally I offer you a hypothetical challenge:-
I would be prepared to offer each pilot in the
company £10 if we have no level busts in 2005. The other side of the
deal is that each pilot in the company gives me £10 if we do have any.
I could win a fortune, you could win a little. Actually, I’d love to
lose because it would mean that you’d all got the message and I’d have
done a good job!
The reality however, is that the bottom line of a level bust is about
much more than a gamble, and the stakes are just too high for any of
us to want to play.
Stay safe, stay SOP.
The Level Bust Tool Kit
The Level Bust Tool Kit can be downloaded from
the
Eurocontrol website
It is well worth a visit. There is considerable
detail available that is relevant to the pilot community, as well as
the other agencies and players who make our business a safe one. The
Toolkit contains Level Bust Briefing Notes, the 14 Briefing Notes are
divided into 3 groups-General (GEN), Aircraft Operators (OPS), and Air
Navigation Service Providers (ATM). These can be accessed
here.
Abbreviations used:
ACAS Airborne
Collision Avoidance System
ANSP Air Navigation
Service Providers
ASR. Air Safety Report
ECAC. European
Civil Aviation Conference
HEIDI. Eurocontrol Harmonisation of European
Incident Definitions Initiative
IATA. International Air Transport Association
NATS National Air Traffic Service (UK)
SOP Standard Operating Procedure
STCA Short Term Conflict Alert
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