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ATS Incidents ATS Incidents Reporting and Reporting and Investigation Investigation TeamsTeams

The Federal Aviation Administration

Presented By:

Rick Baker

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ATS Incident Reporting and InvestigationATS Incident Reporting and Investigation

• Reporting OE/D’s to Team Supervisor• Preliminary Investigation• Headquarters Call-in• Controller Decertification• Final OE Report• Investigation Teams• Follow-Up from Investigation

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Reporting OE/D’s to Team SupervisorReporting OE/D’s to Team Supervisor

• Every controller is responsible to report a loss of separation– Aircraft to Aircraft– Aircraft to Airspace

• Every supervisor is responsible to investigate a reported loss of separation

• Unreported OE/D’s can result in disciplinary action

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Reporting (cont.)Reporting (cont.)

• Safety takes precedence over personal loyalties• Reputation of national ATC system at stake

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Preliminary InvestigationPreliminary Investigation

• Controller relieved from position• Investigation conducted by supervisor

– Controller interviews– Listen to voice tapes– Review computer data

• Management determines if OE/D occurred

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Headquarters Call-InHeadquarters Call-In

• Involves headquarters in QA process– What happened– Who was doing what– What action have you taken

• Required within a pre-determined time limit

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Controller De-certificationController De-certification

• Controller initially relieved from position• Controller may be decertified if OE/D occurred

– Must receive training before returning to work– Could be decertified on one or all positions

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Investigation TeamsInvestigation Teams

– Airspace

– Procedures

– Distractions

– Workload

– Equipment problems

– Supervision

– Weather

– Controller proficiency

Researches and identifies contributing factors

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Final OE ReportFinal OE Report

• Final Analysis of OE/D• Identifies causes of OE/D• Summary of event in time order• Identifies responsible persons• Action taken by facility as a result of OE/D• Report is used in trend analysis

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Follow-Up From InvestigationFollow-Up From Investigation

• Changes to procedures• Changes to airspace• Additional Training• Controller performance review• Supervisory performance review• Follow-Up recorded reviews• Increased oversight by headquarters

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