Download NAM/CAR/SAM Air Traffic Services Quality Assurance

THE ROLE OF THE NTSB IN
ATC INVESTIGATIONS
Richard J. Wentworth
National Resource Specialist (ATC)
Operational Factors Division (AS-30)
NTSB Mission
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To investigate accidents, determine the
probable cause, and develop safety
recommendations to preclude a reoccurrence
Premise for an ATC Investigation
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Anytime there is an accident or incident
in which a pilot was receiving air traffic
control services, one must determine
whether the performance of the
controller (or lack thereof), or the
system, caused or contributed to it.
Background of
NTSB ATC Investigators
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5 full time air traffic control experts with
terminal or en route experience
some are pilots
minimum of 14 years of experience
Initiating the Investigation
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What was the last ATC facility in
communication with the airplane?
Does the facility record radar data?
Is drug testing of the controller (s)
required?
Is the controller available for interview?
Other Considerations
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Is weather a factor?
Are procedures a factor?
Are communications a factor?
Is human performance a factor?
Are there corporate culture issues
involved?
Is facility equipment or maintenance an
issue?
Is hardware/software a factor?
Parties
The primary purpose of permitting the
participation of organizations in an
accident investigation is to assist the
Board in developing a complete and
accurate factual record of the accident.
Parties to an ATC Investigation
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The Federal Aviation Administration
The aircraft operator union
representative for either/both the
controllers and the pilots
Investigation bureau for country of origin
Manufacturer
Operator
State of registry
Group Chairman’s Responsibility
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Manage the ATC investigation and keep
the Investigator-in-charge informed
review all required documentation
focus on the issues
development of group notes or “field
notes”
produce an investigative and analytical
report
Arrival at the ATC Facility
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In-briefing by facility personnel
Listen to recorded voice
communications
Tour of the facility
Review training record of controller
Review documentation
Develop interview schedule
Data Used to Conduct an ATC
Investigation
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recorded voice
communications
recorded radar
data
flight progress
strips
personnel
statements
tower/control room
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weather data
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facility procedures
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position logs
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traffic management
logs
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equipment logs
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facility evaluations
Most Common ATC Human
Performance Errors
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Read back/hear back
Failure to follow procedures
Distractions
Forgetting
Phraseology
workload
Investigating Incidents
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The investigation of air traffic control
incidents is critical in determining the
“health”of the ATC system and assists
the investigator to identify trends which
in turn will support corrective measures
More Common Incidents
the NTSB Investigates
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Surface Incidents
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Near Mid-air Collisions
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Operational Errors
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Any serious incident at the request of
another agency/country
System Management
Korean Air flight 801, a Boeing 747
Nimitz Hill, Guam
August 6, 1997
Aircraft Accident
N2281W, a Piper PA-32-300
near Brandywine, Maryland
October 2, 1996 at 1112
EDT
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