| The Level Best
Campaign
Click here if you have
problems playing the Levelbust 2 DVD
(now out of stock, but you can view the video
here
courtesy of
Scott International Procedures)
Latest updates December 2008 here
A message from Peter Riley, Level Bust Working
Group Lead
here
The Scale of the Problem:
NATS figures for Level Busts & Losses of Separation
2004 to end of October 2008
Click to enlarge
Source: NATS Division of Safety
The bars represent reported Level Busts – this is not the whole
story. The only statistics we are sure we capture
correctly are the Level Busts which cause a loss of separation.
We estimate that the number of reported Level Busts represents
approximately 30% of the actual number of Level Busts
During this campaign, we would like to see:
An INCREASE in the proportion of
level busts which are reported, we want all events to be reported because
we need to understand the full scale of the problem Level Busts resulting in a loss of
separation DECREASE
You will find articles and posters, which you
are welcome to use, as well as other information on Level Busts and
tips on how to avoid them.
If you have a comment about Level Busts, or
about this campaign, please e-mail us on the feedback form: every
piece of information, comment, or experience is very useful to us. We
are especially interested in which sector of the aviation industry you
are employed in. Please use the drop down box on the
feedback page to indicate this. Also, if
you'd like to be informed when this website is updated please tick the
box on the feedback form.
A
message from Peter Riley, Level Bust Working Group Lead:
I thought it appropriate to update you on the last quarter’s level
bust performance and activities. Please see above the level bust
data from Oct 2008. This shows that level bust reports are steady at
about the 450 mark in the
rolling 12
month total, and have been for the last year or so. Whilst we
can take some consolation from the fact that this has been against
rising traffic levels during this period, it does illustrate the
stubborn persistence of this error type and its effect on
SSE numbers – which is largely unchanged. In
fact any cause for heightened optimism about a better safety
performance in 2008/9 than 2007/8, was significantly diluted by a
bad October for level busts with 1 SSE2a and 3 SSE3b. So whilst the
most serious events (SSE1&2) are still somewhat lower than this time
last year, the number of slightly less serious losses of separation
(SSE3a+b) has more than doubled – underlining the fact that there is
no room for complacency on level busts...
So what have we been doing about it during the last few months?
With regards to maintaining the momentum of awareness and education
activities I can report meetings to discuss individual operator
performance; a presentation to the RETRE conference in Arundel to
senior training captains in the UK and US aviation industry, as well
as another to 70 or so CAA IRT Examiners in Oxford. A presentation
was also delivered to students and instructors at the ATC College.
Wallcharts providing mapped details of individual operator level
busts have been provided to several airlines and have been
well-received. You may have seen the ‘Level
Busts – Learning the Hard Way’ article reproduced recently in
the GATCO magazine, Transmit. We have also had an
article on business aviation level busts published in the Flight
safety Foundation’s magazine AeroSafety World. We have also held
meetings of the NATS Level Bust Working Group and the UK Level Bust
Working Group during November.
The Level Bust Questionnaire responses (54 from 87 sent out by the
beginning of October) has provided a good return rate at 62% and
produced some good data to help in the analysis of causal factors.
On some occasions it appears that the information in the LBQs may
not have been used to update causal factors
ascribed during investigations; consequently we continue to have a
high number of level busts reported which have the less than helpful
‘Correct pilot readback followed by incorrect action’ as the primary
‘cause’ for the incident. It would be helpful if investigators could
check responses in the level bust questionnaire and update the
causal factors in STAR. In the longer term this should enable more
focussed strategies to be developed to counter level busts. With
regards to our strategy going forward, I am very grateful for the
input you have provided into the level bust element for the new
Strategic Plan for Safety; I believe we are ahead of other
workstreams in this respect.
On the technology and airspace development theme there has been some
progress in establishing reporting points to replace DME distances
from a beacon, a known cause of some level busts in Swanwick
airspace. Much time has also been spent arguing the case for Cleared
Flight Level / Mode S Selected Flight Level conformance alerting
with the introduction of Electronic Flight Data, while in the longer
term we would like to see some form of system resilience against
altimeter setting error, which has again come to prominence during
November. News of deferral of the Midland and Manchester TMA
airspace projects have added weight to this, with questions being
raised over the timescales for the introduction of the common
Transition Altitude.
That’s all for now. I’d like to take the opportunity to thank
everybody who continues to contribute to the activities of the level
bust workstream for your help and support.
Pete Riley, December 2008
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