1. THE ROLE OF THE NTSB IN ATC INVESTIGATIONS
Richard J. Wentworth
National Resource Specialist (ATC)
Operational Factors Division (AS-30)

2. NTSB Mission
To investigate accidents, determine the probable cause, and develop safety recommendations to preclude a re-occurrence

3. 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.

4. 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

5. 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?

6. 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?

7. 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.

8. 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

9. 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

10. 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

11. 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

12. Most Common ATC Human Performance Errors
Read back/hear back
Failure to follow procedures
Distractions
Forgetting
Phraseology
workload

13. 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

14. More Common Incidents the NTSB Investigates
Surface Incidents
Near Mid-air Collisions
Operational Errors
Any serious incident at the request of another agency/country

15. Korean Air flight 801, a Boeing 747
System Management
Korean Air flight 801, a Boeing 747
Nimitz Hill, Guam
August 6, 1997

18. Aircraft Accident N2281W, a Piper PA-32-300 near Brandywine, Maryland
October 2, 1996 at 1112 EDT

23. Video