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THE ROLE OF THE NTSB IN ATC INVESTIGATIONS
Richard J. WentworthNational Resource Specialist (ATC)Operational Factors Division (AS-30)
NTSB Mission
To investigate accidents, determine the probable cause, and develop safety recommendations to preclude a re-occurrence
Premise for an ATC Investigation
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
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
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
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?
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
Parties to an ATC Investigation
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
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
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
recorded voice communications
recorded radar data flight progress strips personnel
statements tower/control room
layout
weather data facility procedures position logs traffic management
logs equipment logs facility evaluations
Most Common ATC Human Performance Errors
Read back/hear back Failure to follow procedures Distractions Forgetting Phraseology workload
Investigating Incidents
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
Surface Incidents
Near Mid-air Collisions
Operational Errors
Any serious incident at the request of another
agency/country
Korean Air flight 801, a Boeing 747
Nimitz Hill, Guam
August 6, 1997
System Management
N2281W, a Piper PA-32-300
near Brandywine, Maryland
October 2, 1996 at 1112 EDT
Aircraft Accident
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