1. 1 ATS Incidents Reporting and Investigation Teams The Federal Aviation Administration Presented By: Rick Baker

2. 2 ATS Incident Reporting and Investigation Operational Error Operational Deviation

3. 3 ATS Incident Reporting and Investigation Reporting Suspected Events Preliminary Investigation Investigation Teams Controller Decertification Final OE Report Follow-Up from Investigation

4. 4 Reporting Suspected Events Every controller is responsible to report a loss of separation to the supervisor –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

5. 5 Reporting (cont.) Safety takes precedence over personal loyalties Reputation of national ATS system at stake

6. 6 Preliminary Investigation Controller relieved from position Investigation conducted by supervisor –Controller interviews –Listen to voice tapes –Review computer data –Gather pertinent data Management determines if OE/D occurred

7. 7 Investigation Teams –Airspace –Procedures –Distractions –Workload –Equipment problems –Supervision –Weather –Controller proficiency Researches and identifies contributing factors such as:

8. 8 Controller Decertification Controller initially relieved from position Controller may be decertified if OE/D occurred –Must receive training before returning to work –Must be recertified by supervisor Could be decertified on one or all positions

9. 9 Final OE/D 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

10. 10 Follow-Up From Investigation Changes to procedures Changes to airspace Additional training Controller performance review Supervisory performance review Follow-up tape reviews Increased oversight by headquarters

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