THE ROLE OF THE NTSB IN ATC INVESTIGATIONS Richard J. Wentworth National 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?

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 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 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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