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for which flight progress strips were designed, puts a premium on the necessity to actively and
constantly monitor the IM. While NAV CANADA does provide direction to all controllers on
scanning techniques, that subject matter is more oriented to flight progress strip scanning
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procedures than to definable techniques associated with how to maintain full-time attentive
radar flight monitoring. In this occurrence, the radar controller’s full-time attentive flight
monitoring procedure did not meet the level of attentiveness required to provide an adequate
level of safety to the aircraft under his control, and, as a result, the radar controller did not
recognize the conflict and did not provide air traffic control radar separation between the two
aircraft.
2.2.3 Conflict Resolution
Devising a specific separation plan is predicated on recognizing that a situation exists that
requires specific action. The benefits of adding specific markings to strips in accordance with
articles 2.4 and 8.3.2 of the Gander ACC Operations Manual are restricted to their use as memory
aids in that the use of the warnings presupposes that potential conflicts have been recognized. If
no conflict is identified, no warning markings are added. Review of the flight progress board for
conflicting traffic at common points and full-time attentive flight monitoring of the IM are often
the triggering events that enable radar controllers to recognize potential conflicts and to begin
the action planning process. Where there is no obvious conflict indicated on the flight progress
board (the two aircraft were not posted under a common point and none of the required
markings were on either of the flight progress strips), or where the conflict is overlooked during
the monitoring process, the radar controller may not devise a specific separation plan and thus
may perform no specific separation actions. Where task design does not encourage effective
team problem solving, the necessary team planning step may not be accomplished, and the
radar controller in his or her tactical control decisions becomes the single, ground-based point of
defence against airborne collisions. That defence broke down when the radar controller did not
identify the conflict during his monitoring of the tactical situation on the IM. The team
supervisor was unable to intervene as a final level of quality control because he was occupied
controlling in another sector, and, in any case, his duties preclude detailed knowledge of the
control actions of all the controllers in all the sectors of the specialty. There was no procedural or
technological defence in the design of this air traffic control process to contain this situation once
the radar controller missed the developing conflict.
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3.0 Conclusions
3.1 Findings
4. The controllers involved in this occurrence were qualified and current.
5. All equipment available to the controllers was serviceable and being used.
6. Staffing in the sector met unit standards. The supervisor was working in another sector
at the time of the occurrence.
7. The workload was assessed as heavy.
8. The radar controller did not devise an active separation action plan because he did not
recognize the need for one.
9. The flight progress strips for ACA870 were not marked with the various symbols
specified in the Gander ACC Operations Manual indicating that the flight required
special attention.
10. The sector controllers’ performance of their duties, seemingly in conformance with the
directives and the task design in the Gander ACC Operations Manual, did not lend
itself to effective sector team problem solving and separation planning, which resulted
in the loss of an effective defence.
11. The placement of the two flight progress strips under two separate fixes did not overtly
warn the radar controller that the two aircraft at the same altitude would be in close
proximity in the vicinity of one of those fixes.
12. There was no rigorous training on radar monitoring methods provided to these
controllers in basic air traffic control training or during refresher or specialty training
after initial qualification.
13. The TCAS RAs received by the crews of ACA870 and AFR033 provided the only
warning and successful resolution to the traffic conflict.
14. Though planned for implementation to meet traffic needs in the early 1990s, a
functioning automated conflict alert tool was not available.
15. The Canadian Aviation Safety Board (CASB), the predecessor to the TSB, in 1990,
recommended that the air traffic service provider accelerate all initiatives with a
potential for providing controllers with automated conflict prediction and alerting.
　
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