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

2. ATS Incident Reporting and Investigation
Reporting OE/D’s to Team Supervisor
Preliminary Investigation
Headquarters Call-in
Controller Decertification
Final OE Report
Investigation Teams
Follow-Up from Investigation
Define OD/E
During this presentation we will outline the process used in the US when there is reason to believe an error has occurred.
Here is a list of the major activities that occur after an OE/D

3. Reporting OE/D’s to Team Supervisor
Every controller is responsible to report a loss of separation
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
Identifying an error is everyone’s responsibility. In a tower environment if the ground controller sees the local controller have two aircraft on the runway at the same time, he has a responsibility to bring this to the supervisor’s attention.
A loss of separation can be Aircraft to Aircraft (less than 5 miles or 1000’) OR
Aircraft to airspace—no handoff, no point-out
Supervisor responsibilities
Unreported OE/Ds result in discipline

4. Reporting (cont.) Safety takes precedence over personal loyalties
Reputation of national ATC system at stake
Personal Loyalties
Reputation of national ATC system is at stake—Integrity

5. Preliminary Investigation
Controller relieved from position
Investigation conducted by supervisor
Controller interviews
Listen to voice tapes
Review computer data
Management determines if OE/D occurred
After the supervisor has been advised that an OE/D MAY have occurred he:
Relieves controller from position
This not punitive
Initial Investigation by supervisor
Controller interviews
listen to voice tapes
review computer data, if available
Management ultimately determines if a loss of separation occurred.
Supervisor provides the information necessary to make determination.

6. Headquarters Call-In Involves headquarters in QA process What happened
Who was doing what
What action have you taken
Required within a pre-determined time limit
The FAA requires a call-in, a phone call, from the facility that had the error to FAA headquarters within 3 hours of the error.
Purpose of call-in
VIP
newsworthy events
informational
problem facilities
What happened, how did the error occur?
What positions were staffed, what was the supervisor doing?
What was the weather?
What action has the facility taken?
Removed controller from position?
Pulled voice tapes?
Again, a time limit is important so field facilities will get the information to headquarters as soon as possible.

7. Controller De-certification
Controller initially relieved from position
Controller may be decertified if OE/D occurred
Must receive training before returning to work
Could be decertified on one or all positions
When it is determined, yes, this event was indeed an OE/D, controllers are usually decertified. This is different from the initial relieving from position. When a controller is decertified, he can not go back to work until he is re-certified. Re-certification involves additional training, practice problems or a review of procedures.
A controller involved in an error could be decertified on one or all positions

8. Investigation Teams Researches and identifies contributing factors
Equipment problems
Supervision
Weather
Controller proficiency
Airspace
Procedures
Distractions
Workload
An investigation team can be formed to determine what factors contributed to the OE/D. This team is made up of the involved controller, a member of management, a member of the QA department and a union representative.
The team will consider all factors that may have contributed to the error.
Airspace—does a sector boundary need to be moved? Do airways need to be rerouted to provide additional safety margins…
Procedures—is there an AIT procedure that contributed, maybe everyone did not understand the procedure the same way. Does an LOA have a problem that contributes.
Distractions—is the control room environment noisy, was one controller/supervisor/visitor distracting the controller
Workload—did the controller need additional help that was not provided? Does the sector get too busy on a daily basis, maybe an airspace change is in order
Equipment problems—poor radio or radar coverage
Supervision—what was the sup doing when the error occurred? Did he have the positions appropriately staffed/
Weather—was sever weather impacting the position?
Controller proficiency—is the controller sufficiently trained, skill level

9. Final OE 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
Report is used in trend analysis
The Final OE report is a formal document that consists of several elements. This report is sent to headquarters 30 days after an OE occurs.
Final Analysis—what was the result of the investigation
Identifies the cause of the error—missed readback, insufficient vectors to provide separation
Chronology of event—controller signed on at this time, aircraft 1 checked on at this time, controller issued descent clearance at this time, etc
Responsible controller is named
Action taken by facility—controller was decertified and received 20 hours of OJT on local control; new procedure was developed, airspace was redesinged.
Report is used by headquarters to study OE/D trends. For instance a trend might indicate that most errors occur during the same time period on a Friday. This could indicate additional controllers were needed for this 2 hour period.

10. Follow-Up From Investigation
Changes to procedures
Changes to airspace
Additional Training
Controller performance review
Supervisory performance review
Follow-Up recorded reviews
Increased oversight by headquarters
Quality Assurance almost always involves change. The follow-up after an OE/D is important because it is this follow-up that can prohibit the same error from happening again. The Investigation Team will frequently suggest changes to:
Procedures—Are changes to LOA’s needed
Airspace—maybe a sector redesign team should be formed
Additional Training—this additional training could involve only the controller who had the error, or it could mean retraining the entire facility on the use of a particular procedure. Example: Visual Separation in ARTCC
Controller Performance Review—A supervisor will plug-in and monitor a controller at 30 days and 6 months following an error. A grade sheet is completed and placed in training file.
Supervisory Performance Review—if supervisor is found to be contributory to error, what follow-up will be done to correct his deficiency?
Tape Talks
Increased oversight by headquarters—some facilities have proven they need additional help managing their OE/D rate. FAA headquarters may provide additional scrutiny until the problems are resolved and the error rate is lowered.