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

Video