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

2. 2 ATS Incident Reporting and Investigation Reporting OE/Ds to Team Supervisor Preliminary Investigation Headquarters Call-in Controller Decertification Final OE Report Investigation Teams Follow-Up from Investigation

3. 3 Reporting OE/Ds 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/Ds can result in disciplinary action

4. 4 Reporting (cont.) Safety takes precedence over personal loyalties Reputation of national ATC system at stake

5. 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

6. 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

7. 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

8. 8 Investigation Teams –Airspace –Procedures –Distractions –Workload –Equipment problems –Supervision –Weather –Controller proficiency Researches and identifies contributing factors

9. 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

10. 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

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