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Air Navigation Services Provider (ANSP)

ANS SAFETY DIVISION

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ATS SAFETY PERFORMANCE INDICATORS

H1 – Serious Incident

H2 – Loss of Separation

H3 – Runway Incursion

H4 – Runway Excursion

L1 – TCAS RA

L2 – Level Bust

L3 – Large Height Deviation

L10 – Go Around due to Inadequate Spacing

HIGH CONSEQUENCES

LOW CONSEQUENCES

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Hotspot Area : LOSS OF SEPARATION

Top Contributing Factors;

ATC Error
Airspace Complexity

Action

BOI
Re-training
Improve Coordination Procedure with adjacent units

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Hotspot Area : RUNWAY INCURSION

Top Contributing Factors;

Communication Error
ATC Error
Equipment – stop bar

Safety Measures

BOI
Re-training

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5

4

2

1

2

1

2023 - 2024

TCAS RA vs TIME (UTC)

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Hotspot Area : TCAS RA

Top Contributing Factors;

High ROC/ROD
ATC Error

Recommendation:

AIP Malaysia ENR Para 1.7.7.4 to mitigate the risk of TCAS RA

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Hotspot Area : En-Route

Jan 2024 : PADLI

Feb 2024 : PULIP

Mar 2024 : PIBOS

High rate of descend or climb.

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May 2024 : NUKPA

Sep 2023 : NUKPA

Oct 2023 : NUKPA

Issue hearback and readback.

ATC Error.

Hotspot Area : Approach

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2023 - 2024

TCAS RA Root Cause

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CAAM STAKEHOLDER ENGAGEMENT

COMMITTEE

PILOT ERROR FLOWN DIFFERENT SID

25^TH JUNE 2024

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No.	Date of Occurrence	Time (UTC)	FINDING	Rwy
1	17/06/2023	0320	Checked with ACD and from the audio recording, the readback by the pilot AIRLINE A was correct, MITOS 1C. But the pilot airborne following MITOS 2C (Midnight SID 1600-2100 UTC).	15
2	23/06/2023	0052	Checked with ACD and from the audio recording, the readback by the pilot AIRLINE A was correct, KIMAT 1C. But the pilot airborne following KIMAT 2C (Midnight SID 1600-2100 UTC).	15
3	06/07/2023	0632	Checked with ACD and from the audio recording, the readback by the pilot AIRLINE A was correct, KIMAT 3F. But the pilot airborne following KIMAT 2F (Midnight SID 1600-2100 UTC).	33
4	02/08/2023	1052	Checked with ACD and from the audio recording, the readback by the pilot AIRLINE Y was correct, BIKDU 3C. But the pilot airborne following BIKDU 2C (Midnight SID 1600-2100 UTC).	15

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No.	Date of Occurrence	Time (UTC)	FINDING	Rwy
5	06/10/2023	0246	Checked with ACD and from the audio recording, the ACD clearance given was BIKDU 3C, however, the readback by the pilot AIRLINE A was incorrect, BIKDU 1C (no longer available). But the pilot airborne following BIKDU 2C (Midnight SID 1600-2100 UTC).	15
6	22/02/2024	0938	Checked with ACD and from the audio recording, the readback by the pilot AIRLINE S was correct, MITOS 1D. But the pilot airborne following MITOS 2D (Midnight SID 1600-2100 UTC).	32R
7	28/04/2024	0433	AIRLINE A misunderstanding the ACD clearance. ACD clearance issued was BIKDU1F, runway 33 and the read back by the pilot was correct. But the pilot airborne following BIKDU 2F (Midnight SID 1600-2100 UTC).	33

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OCCURRENCE BY AIRLINE

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ADHERENCE TO ATC CLEARANCE 28 FEB 2024

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